Alimentary Pharmacology & Therapeutics | 2021
Editorial: trends in alcohol use and alcohol‐related liver disease in the US population
Abstract
The World Health Organization estimates that harmful alcohol use contributes to three million deaths globally each year.1 Alcoholrelated liver disease (ALD) is a major contributor to that estimate, existing on a spectrum that includes reversible steatohepatitis, alcoholrelated hepatitis and cirrhosis.2 The latter two conditions are associated with significant morbidity and mortality due to limited treatment options. ALD is projected to continue to rise in prevalence in the coming decade, particularly as a proportion of liver diseases due to the rapid advancement in hepatitis C treatments.3 Therefore, we read with great interest this study by Singal et al. that sought to explore host factors associated with the alcohol use and ALD in the US.4 The authors identified individuals with harmful alcohol use through the National Health and Nutritional Examination Survey (NHANES), analyzed admissions for ALD using the National Inpatient Sample (NIS), and used the United Network for Organ Sharing (UNOS) database to identify ALD liver transplant listings. The aim was to provide a bird’seye view of the full spectrum of ALD. On weighted analysis of 15 981 individuals in the NHANES database, 17.7% reported harmful alcohol use. This behaviour was associated with young age, male gender and Hispanic race/ethnicity. On regression analysis, both female gender and Hispanic race/ethnicity were associated with increased risk of acute on chronic liver failure. Review of the UNOS database highlighted that liver transplant listings for young individuals increased from 2% to 5% from 2006 to 2016. While there were limitations to this study given its retrospective nature and use of unlinked databases, these data may help better identify individuals at highest risk for harmful alcohol use and severe ALD. We agree with the authors that corroboration with prospective studies is an essential next step, with particular attention to racial/ethnic and genderbased disparities. This study also reinforced prior data that while rates of alcohol use disorder (AUD) are higher in men, women may experience a higher frequency of medical complications related to alcohol use including ALD.5 This may be driven by not only differences in metabolism, but also by differential patterns of alcohol use. Women start drinking at a later age, but studies suggest they increase their rate of alcohol consumption and progress to severe AUD more rapidly than men.6 The trend of AUD and severe ALD in young individuals is also concerning and has been exacerbated in the setting of the COVID19 pandemic. Survey data indicate increased alcohol consumption secondary to stress and boredom over the past year.7 In a survey of approximately 400 hepatology and gastroenterology providers, only 61% routinely refer patients with ALD and AUD for behavioural therapy.8 Behavioural and pharmacotherapy for AUD are essential components of the treatment of ALD. Additional training in the identification, prognostication and ultimately linkage to treatment of AUD is needed for both primary care and subspecialty providers. Future studies should aim to further refine risk factors and work to find effective interventions.