Limited Alcohol Consumption May Be Safe in Early Stages of Steatotic Liver Disease

Yee Hui Yeo, MD

Credit: @YeeHuiYeo1 on X

Patients with steatotic liver disease (SLD) are generally advised to abstain from consuming alcohol, but findings from a recent study are providing novel insight into the extent to which alcohol consumption exacerbates disease progression, defining a potential ‘safe’ threshold for this patient population.¹

Using the fibrosis-4 index (FIB-4) score to classify patients’ risk of fibrosis, investigators determined those in the early stages of SLD deemed to be at low risk for advanced fibrosis can consume < 7.4 grams of alcohol per day without increasing their risk of advanced fibrosis.¹

“A critical gap in our understanding of steatotic liver disease progression has been the lack of concrete data to define a 'safe' level of alcohol consumption for those patients who can’t quit drinking. Our study addresses this unmet need by providing empirical evidence on the relationship between alcohol intake levels and the progression of early-stage disease,” Yee Hui Yeo, MD, primary investigator of the study and a clinical fellow in the Karsh Division of Gastroenterology and Hepatology at Cedars-Sinai, said in a press release.²

Individuals with certain cardiometabolic risk factors or who consume unhealthy amounts of alcohol are more likely to develop SLD. Given the lack of specific treatments or medications, disease management involves lifestyle modifications for managing risk factors contributing to the condition. As such, those with SLD are often encouraged to avoid alcohol consumption – however, little is known about how much alcohol these patients may be able to healthily consume if they choose not to abstain from drinking.³

To elucidate the dose-dependent association of alcohol use with SLD progression, investigators obtained data from the US National Health and Nutrition Examination Survey III (1988-1994) database and reviewed participant health surveys to identify a safe threshold for alcohol consumption. SLD was defined as ultrasonography-confirmed hepatic steatosis. Investigators determined the risk of fibrosis in patients with SLD using the FIB-4 score, defining intermediate/high risk as a score ≥ 1.3.¹

Of 2834 individuals with SLD, 20.8% (n = 591) had an intermediate or high risk of advanced fibrosis and the remaining 2243 patients were determined to have a low risk of advanced fibrosis. During 66,299 person-years of follow-up, individuals at intermediate or high risk for advanced fibrosis had a mortality rate of 4342 per 100,000 persons compared with 1099 per 100,000 persons in the low-risk group.¹

After adjustment for demographic characteristics and metabolic variables, investigators used restricted cubic spline curves to identify a nonlinear association between alcohol consumption and mortality in the low-risk group (P = .001 for nonlinearity). At a 7.4-gram daily intake, investigators noted the mortality risk exceeded an adjusted hazard ratio (HR) of 1.00 (HR, 0.99).However, in the intermediate/high-risk group, a linear association between daily alcohol consumption and increased risk of mortality was observed (P = .65 for nonlinearity).¹

“While it is still best to counsel abstinence for patients with this liver disease, the study defines a threshold beyond which alcohol consumption can increase mortality. The results provide new guidance for clinicians and patients,” Shelly Lu, MD, the women's guild chair in gastroenterology and director of the division of digestive and liver diseases at Cedars-Sinai, said in a press release.²

Despite the potential significance of these findings, several potential limitations were outlined. These included the reliance on self-reported alcohol use, lack of consideration for drinking patterns, inability to track alcohol intake changes past what was reported at baseline, and the population-based nature of the data.¹

“We favor abstinence as the safest course of action for these patients. But for those who are not able to stop drinking, these findings provide concrete guidelines for making decisions about their health and lifestyle,” Yeo concluded.²

References:

1. ^{Yeo YH, Zhu Y, Arab JP, et al. Alcohol Intake Thresholds Among Individuals With Steatotic Liver Disease. JAMA Netw Open. 2023;6(12):e2347548. doi:10.1001/jamanetworkopen.2023.47548}
2. ^{Cedars-Sinai. Some Patients With Liver Disease May Tolerate Small Amounts of Alcohol Without Getting Sicker. Newswise. February 28, 2024. Accessed March 5, 2024. https://www.newswise.com/articles/some-patients-with-liver-disease-may-tolerate-small-amounts-of-alcohol-without-getting-sicker}
3. ^{Cleveland Clinic. Steatotic (Fatty) Liver Disease. Diseases & Conditions. September 27, 2023. Accessed March 5, 2024. https://my.clevelandclinic.org/health/diseases/15831-fatty-liver-disease}