for Health Care Providers
Alcohol and Viral Hepatitis
When counseling a patient with viral hepatitis, it is critical to evaluate the patient's history of and current use of alcohol and to counsel on recommendations about alcohol use. Generally speaking, alcohol is a toxin to the liver, and alcohol in combination with viral hepatitis can have a synergistic effect on causing inflammation to the liver.
Observational studies of alcohol and viral hepatitis can be complicated by the issue of patients' self-reported alcohol intake, as patients are often inaccurate in their estimate or their recall, and are often not willing to report their true alcohol intake. Therefore, data on alcohol use in general needs to be interpreted in light of the knowledge that self-reported alcohol use can be inaccurate, and likely under reported.
Research has shown that fibrosis scores in hepatitis C patients have correlated with patients' degree of alcohol use. There is strong evidence that heavy alcohol use (>50 grams per day) is associated with higher likelihood of advanced fibrosis in hepatitis C patients. However, evidence also exists showing lesser degrees of alcohol intake being associated with higher fibrosis scores and higher HCV RNA levels. Some data have shown a relationship between alcohol use and HCV RNA viral loads and response to treatment. Controversy exists on the question of whether any amount of alcohol is safe in patients with hepatitis C. The AASLD hepatitis C guidelines from 2009 recommend counseling all patients with hepatitis C to abstain from alcohol use.
It is important to note that there is no evidence supporting a minimum length of abstinence for substance use or alcohol use disorders as a requirement for starting anti-viral HCV treatment. There is abundant evidence from VA researchers that anti-viral treatment can be as successful in Veterans with mental health and substance use (MH/SUD) conditions as in patients without these disorders, if access to appropriate MH/SUD care is provided and patients adhere to prescribed anti-viral therapy. Among patients who complete anti-viral therapy, cure rates are similar in drinkers, recent abstainers, and non-drinkers. Guidelines issued by the National Institutes of Health and the VA's National Hepatitis C Program recommend case-by-case evaluation of such patients for anti-viral therapy, rather than automatic exclusion due to MH/SUD co-morbidities.
Among hepatitis B patients, intake of 30 grams per day in men and 20 grams per day in women has been associated with higher fibrosis scores. Furthermore, in hepatitis B patients, data suggest that alcohol can increase the risk of fibrosis progression as well as heighten the risk of developing cirrhosis and HCC. The AASLD hepatitis B guidelines from 2009 recommend counseling all patients with hepatitis B to abstain from, or have only limited amounts of alcohol.
Patients who have developed cirrhosis from either hepatitis B or hepatitis C should be counseled to completely abstain from alcohol use. Avoiding alcohol is a primary principle of cirrhosis management to lessen the risk of decompensation and avoid any further insult to the cirrhotic liver.
Given the high prevalence of drinking in Veterans with liver disease, providers treating liver disease are strongly encouraged to collaborate with local substance abuse clinics and mental health providers to address this critical component of overall viral hepatitis patient care.
Diagnosis, Management, and Treatment of Hepatitis C: An Update
Ghany M, Strader D, Thomas D et al; Hepatology, Vol. 49, No. 4, 2009, 1335-1374