Journal Article Annotations
2017, 4th Quarter

Infectious Diseases

Annotation by Aum A. Pathare, MD
January 2018

The contribution of alcohol use disorder to decompensated cirrhosis among people with hepatitis C: an international study

PUBLICATION #1 — Infectious Diseases

The contribution of alcohol use disorder to decompensated cirrhosis among people with hepatitis C: an international study

Alavi M, Janjua NZ, Chong M, et al

Abstract: J Hepatol. 2017 Oct 26. pii: S0168-8278(17)32398-X

Background & Aims: The advent of direct-acting antivirals (DAAs) has led to ambitious targets for hepatitis C virus (HCV) elimination. However, in the context of alcohol use disorder the ability of DAAs to achieve these targets may be compromised. The aim of this study was to evaluate the contribution of alcohol use disorder to HCV-related decompensated cirrhosis in three settings.

Methods: HCV notifications from British Columbia, Canada; New South Wales, Australia, and Scotland (1995-2011/2012/2013, respectively) were linked to hospital admissions (2001-2012/2013/2014, respectively). Alcohol use disorder was defined as non-liver-related hospitalisation due to alcohol use. Age-standardised decompensated cirrhosis incidence rates were plotted, associated factors were assessed using Cox regression, and alcohol use disorder-associated population attributable fractions (PAFs) were computed.

Results: Among 58,487, 84,529, and 31,924 people with HCV in British Columbia, New South Wales, and Scotland, 2,689 (4.6%), 3,169 (3.7%), and 1,375 (4.3%) had a decompensated cirrhosis diagnosis, and 28%, 32%, and 50% of those with decompensated cirrhosis had an alcohol use disorder, respectively. Age-standardised decompensated cirrhosis incidence rates were considerably higher in people with alcohol use disorder in New South Wales and Scotland. Decompensated cirrhosis was independently associated with alcohol use disorder in British Columbia (aHR 1.92; 95% CI 1.76-2.10), New South Wales (aHR 3.68; 95% CI 3.38-4.00) and Scotland (aHR 3.88; 95% CI 3.42-4.40). The PAFs of decompensated cirrhosis-related to alcohol use disorder were 13%, 25%, and 40% in British Columbia, New South Wales and Scotland, respectively.

Conclusions: Alcohol use disorder was a major contributor to HCV liver disease burden in all settings, more distinctly in Scotland. The extent to which alcohol use would compromise the individual and population-level benefits of DAA therapy needs to be closely monitored. Countries, where appropriate, must develop strategies combining promotion of DAA treatment uptake with management of alcohol use disorders, if World Health Organization 2030 HCV mortality reduction targets are going to be achieved.

Lay Summary: The burden of liver disease has been rising among people with hepatitis C globally. The recent introduction of highly effective medicines against hepatitis C (called direct-acting antivirals or DAAs) has brought renewed optimism to the sector. DAA scale-up could eliminate hepatitis C as a public health threat in the coming decades. However, our findings show heavy alcohol use is a major risk factor for liver disease among people with hepatitis C. If continued, heavy alcohol use could compromise the benefits of new antiviral treatments at the individual- and population-level. To tackle hepatitis C as a public health threat, where needed, DAA therapy should be combined with management of heavy alcohol use.

On PubMed: J Hepatol. 2017 Oct 26. pii: S0168-8278(17)32398-X

Annotation

Type of study: Retrospective population-based cohort study

The finding: Generally, the predictors of disease advancement in patients with HCV infection appear to be older age, coupled with more recent notification of HCV status, male gender, and co-infection with HBV/HIV. Alcohol use disorder contributes to increased rates of decompensated cirrhosis in patients with HCV infection, and liver disease progressing at a younger age.

Strength and weaknesses: The large sample size of this study, along with its inclusivity, are major strengths of this study. The general data collection spans more than 16 years, and age-standardized measures have been derived from at least 7 years of information. These findings, albeit from high income economies, show similar trends at all three sites of the study.

Weaknesses include definitions of decompensated cirrhosis, which were not validated with this diagnosis, and the determination of infection status being made with antibodies without RNA confirmation. There also appears to be potential for underestimation of alcohol use and overestimation of the impact of more severe forms of alcohol use disorder, whereas the effects of antiviral treatment were not evaluated.

Relevance: Psychosocial factors play a significant role in liver disease progression after HCV infection. Patients with HCV have an increased likelihood of problematic alcohol use, which could also limit the potential utility of antiviral medications, increase risk of decompensated cirrhosis, and mortality from liver disease, at a younger age. The benefits of screening, in cases with HCV infection/cirrhosis and its complications, with even a suspicion of alcohol use based on history, laboratory studies, or prior records, need to be considered. Consultation liaison psychiatrists in hospital, or integrated care settings, can lead and direct efforts for early detection and treatment.