Alcohol-related Liver Disease The Long and Winding Road

Transcription

1 Alcohol-related Liver Disease The Long and Winding Road Alastair MacGilchrist Edinburgh International Conference of Medicine Past, Present and Future 13 th September 2016

2 Figure 1. Standardised UK mortality rate datadata were normalised to 100% in 1970, and subsequent trends plotted using the software Statistical Package for the Social Sciences. Data are from the WHO-HFA database.4 Analysed by Nick Sheron (September, 2013).

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4 Age standardised mortality rate per 100, Men aged years 80 Women aged years 70 Scotland Other European countries Scotland Other European countries 10 0 England and Wales England and Wales

5 EASR per 100,000 population Chronic Liver Disease and Cirrhosis mortality rates per 100,000 population, Scotland it s the drink. Alcohol kills a Scot every 8 hours 1 in 20 of all deaths in Scotland is due to alcohol twice that of England 1 in 10 of deaths in Scots aged is due to alcoholic liver disease Enough alcohol is sold in Scotland to enable every adult to exceed safe drinking guidelines 5 almost double that of England Britain s consumption has doubled since Alcohol is 70% more affordable than in 1980 Chronic Liver Disease Alcoholic Liver Disease Price Consumption Harm

6 Liver Transplant Complications of cirrhosis bleeding varices, ascites, encephalopathy Stable cirrhosis management detection, HCC surveillance, varices screening and prophylaxis Detection of reversible ARLD LFTs Prevention EXPENSIVE SMALL IMPACT intervention in identified heavy drinkers Public health measures to reduce alcohol consumption CHEAP BIG IMPACT

7 Scottish Liver Transplant Unit Breakdown of Liver Transplants Nov 1992 to March 2015 n /93 93/ /95 95/96 96/ /98 98/99 99/ / / / / / / / / / / / / / / / Hep C ALD HCC / Other PBC NAFLD

8 Alcoholic Hepatitis Diagnosis Prognosis Treatment alcoholic hepatitis ALT to biopsy or not to biopsy?

9 Glasgow Alcoholic Hepatitis Score > 9 = poor prognosis

10 Predicting prognosis in alcoholic hepatitis 28 day mortality DF = Maddrey s Discriminant Function GAHS = Glasgow Alcoholic Hepatitis Score MELD = Model of End Stage Liver Disease

11 STOPAH trial steroids or pentoxifylline in alcoholic hepatitis UK multicentre double-blind, placebo controlled study 1105 patients randomised to prednisolone pentoxifylline prednisolone + pentoxifylline placebo Primary endpoints mortality at 28 days and 90 days.

12 One year survival in all groups

13 Prednisolone vs No Prednisolone Kaplan-Meier Survival Curve P = 0.056

14 Supportive Treatment early treatment of sepsis prevention of spontaneous bacterial peritonitis prevention of variceal bleeding terlipressin and albumin for early HRS nutrition

15 Time between referral to a liver clinic and the first admission with cirrhosis or liver failure

16 Liver Transplant Complications of cirrhosis bleeding varices, ascites, encephalopathy Stable cirrhosis management detection, HCC surveillance, varices screening and prophylaxis Detection of reversible ARLD LFTs Prevention intervention in identified heavy drinkers Public health measures to reduce alcohol consumption

17 2010: AASLD PRACTICE GUIDELINES Alcoholic Liver Disease 2012: EASL Clinical Practical Guidelines: Management of Alcoholic Liver Disease 2016: Draft Alcohol-related Liver Disease Action Plan LFTs?... Think Alcohol! XS Alcohol?... Think LFTs!

18 12 key recommendations including Knowledge Recommended limits on alcohol intake. Skills Be competent to make an assessment of alcohol, including taking a history and using validated tools.

19 Liver Transplant Complications of cirrhosis bleeding varices, ascites, encephalopathy Stable cirrhosis management detection, HCC surveillance, varices screening and prophylaxis Detection of reversible ARLD LFTs Prevention intervention in identified heavy drinkers Public health measures to reduce alcohol consumption

20 Sunday Mail 15 th Jan 2006

21 Affordability index Alcohol-related discharge rates Alcohol affordability and alcohol-related hospital admissions, Affordability Admissions

22 WHO ACTION AREAS- The Best Buys Leadership, awareness, commitment Scottish Policy National Action Plan Health services response Community and workplace action Brief Intervention Programme Investment in treatment Local Focus on Alcohol projects Drink driving policies Reduce legal limit to 50mg % Ensure enforcement Availability of alcohol Marketing of alcoholic beverages Protection of public health as licensing principle Restriction of in store displays Pricing policies Reducing negative consequences of drinking and intoxication Reduce health impact of illicit alcohol Monitoring and surveillance Minimum unit price law. Banning bulk buy discounts Server training compulsory Not a major issue in Scotland Invest in monitoring/research

23 June 2008

24 May 2012

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26 The Legal Questions for Scottish Court of Session Is Minimum Unit Price a proportionate action in light of the Government s health objectives and free trade obligations? Focus on whether aim of Government is to affect all at risk drinkers or the heaviest drinkers. Is Minimum Unit Price more effective and less trade restrictive than alternative methods, specifically, increasing taxation? Hearings concluded June 2016 Judgement expected September 2016

27 EASR per population Meanwhile, back at the ranch.. Chronic liver disease mortality rates (EASR per ), Scotland, overall and by gender, 1982 to Men EASR Women EASR Both genders EASR

28 Conclusions Despite improvements in treatment of advanced disease, alcohol-related liver disease is a major cause of preventable early death in Scotland The key to further clinical improvements is early detection of reversible disease. Alcohol-related liver disease is highly sensitive to public health and fiscal policy change to reduce alcohol availability, e.g. minimum unit pricing. There is light at the end of the tunnel.