Can Alcohol Consumption Be Recommended in Patients with Liver Disease?

Patients with non-alcoholic fatty liver disease (NAFLD) may benefit from consuming small amounts of alcohol, according to Arthur McCullough, MD, of the Cleveland Clinic in Ohio. That counter-intuitive idea is supported by research that shows that, in patients with NAFLD, benefits accrue for risk of cardiovascular disease (CVD) and even aspects of liver disease, when patients drink no more than 5 to 6 drinks per week.

“I'd ask you to have an open mind that small amounts of alcohol might be beneficial for this disease,” McCullough told the audience at The Liver Meeting, the 63^rd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD).

There is no question that alcohol is “our only socially accepted hepatotoxin,” McCullough said. He pointed out that there are clear dangers from alcohol abuse beyond its hepatotoxic effects. It is estimated that alcoholism costs the United States more than $300 billion per year, and the lifetime incidence of alcohol abuse in the US Is 18%.

Nonetheless, the benefits of consuming small amounts of alcohol are also clearly documented, for both cardiovascular disease and diabetes. “You have a three- to four-fold chance of dying from heart disease as from liver disease,” McCullough said. “We need to stop looking at the problem exclusively through the prism of liver disease.”

The risk of death from all causes, when plotted against alcohol consumption, forms a J-shaped curve, with the risk falling gradually as consumption increases to 5 to 6 drinks per week, then rising more steeply beyond that. The same holds true for death due to CVD alone or stroke alone.

But just as pertinent are the potential benefits of alcohol in the right patient. NAFLD is the most common form of liver disease in the US, occurring in up to one-third of adults. In a recent study of alcohol consumption in NAFLD patients, modest alcohol consumption cut in half the risk of developing non-alcoholic steatohepatitis (NASH), the most progressive form of NAFLD, and an important risk factor for progression to cirrhosis. The risk for fibrosis also decreased, with an odds ratio of 0.58 versus abstinence.

Other studies, including the large National Health and Nutrition Examination Survey (NHANES III), have shown that modest drinking is associated with a lower level of ALT, a marker for liver damage. The J-shaped curve was seen in subjects with low body mass index, while those with high BMI displayed no benefit, but also no increased risk, from modest drinking.

The mechanisms of benefit appear to be linked to an increase in fibrinolysis, an increase in adiponectin, and a decrease in inflammation, McCullough said.

“The benefits of alcohol in NAFLD are likely to be real, I believe,” he said. “Alcohol can provide both hepatic and cardiac benefits.” Nonetheless, he said, clinicians need to remember that these studies are cross-sectional, and that comorbidities must be taken into account.

He recommended alcohol consumption be considered only in biopsy-confirmed NAFLD, with no evidence of cirrhosis. He said that he would also “seriously consider it” in patients with NALFD who also have high cardiac risk.

Clinical Impact:

Will these study results have an impact on your recommendations regarding alcohol consumption in patients with liver disease?