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• W2153359097 abstract "Alcoholic liver disease (ALD) is the most prevalent cause of advanced liver disease in Europe. However, there has been limited research investment into ALD despite its significant burden on the health of Europeans. This disparity is reflected by the ETOh score – the ratio of the estimated population mortality rate to the number of trials focused on a particular disease. The ETOh score for ALD is 358, compared with 1.4 for hepatitis B, 4.9 for hepatitis C, and 15.2 for primary biliary cirrhosis [[1]Shah V.H. Alcoholic liver disease: the buzz may be gone, but the hangover remains.Hepatology. 2009; 51: 1483-1484Crossref Scopus (3) Google Scholar]. In recent years however, the mechanisms driving disease progression and the natural history of ALD have been better defined and novel targets for therapy have been identified [[2]Gao B. Bataller R. Alcoholic liver disease: pathogenesis and new therapeutic targets.Gastroenterology. 2011; 141: 1572-1585Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar]. In addition, significant clinical research has produced a clear framework for the evaluation of new therapies in particular in patients with alcoholic steatohepatitis (ASH). ALD is a complex disease, the successful management of which hinges on the integration of all the competences in public health, epidemiology, addiction behavior and alcohol-induced organ injury. Both primary intervention to reduce alcohol abuse and secondary intervention to prevent alcohol-associated morbidity and mortality rely on the coordinated action of multidisciplinary teams established at local, national, and international levels. These guidelines are largely based on the issues raised during the EASL monothematic conference on ALD held in Athens in 2010. The guidelines have three main aims: (1) to provide physicians with clinical recommendations; (2) to emphasize the fact that alcohol can cause several liver diseases (steatosis, steatohepatitis, cirrhosis), all of which may coexist in the same patient; (3) to identify areas of interest for future research, including clinical trials. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system [[3]Guyatt G.H. Oxman A.D. Kunz R. Falck-Ytter Y. Vist G.E. Liberati A. et al.Going from evidence to recommendations.Br Med J. 2008; 336: 1049-1051Crossref PubMed Google Scholar]. The strength of recommendations thus reflects the quality of underlying evidence. The principles of the GRADE system have been enunciated. The quality of the evidence in these clinical practical guidelines (CPGs) has been classified into one of three levels: high (A), moderate (B) or low (C). The GRADE system offers two grades of recommendation: strong (1) or weak (2) (Table 1). The CPGs thus consider the quality of evidence: the higher the quality of evidence, the more likely a strong recommendation is warranted; the greater the variability in values and preferences, or the greater the uncertainty, the more likely a weaker recommendation is warranted.Table 1Grading of evidence and recommendations (adapted from the GRADE system). Open table in a new tab Alcohol consumption is responsible for 3.8% of global mortality and 4.6% of disability-adjusted life-years (DALYs) lost due to premature death [[4]Rehm J. Mathers C. Popova S. Thavorncharoensap M. Teerawattananon Y. Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders.Lancet. 2009; 373: 2223-2233Abstract Full Text Full Text PDF PubMed Scopus (847) Google Scholar]. The attributable burden in Europe, with 6.5% of all deaths and 11.6% of DALYs attributable to alcohol, is the highest proportion of total ill health and premature deaths due to alcohol of all WHO regions [4Rehm J. Mathers C. Popova S. Thavorncharoensap M. Teerawattananon Y. Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders.Lancet. 2009; 373: 2223-2233Abstract Full Text Full Text PDF PubMed Scopus (847) Google Scholar, 5WHO, European Status Report on Alcohol and Health 2010. Copenhagen: WHO Regional Office for Europe; 2010.Google Scholar]. Europe shows particularly large sex differences in burden: the deaths attributable to alcohol being 11.0% and 1.8% for men and women, respectively. The young account for a disproportionate amount of this disease burden, with an alcohol-associated mortality over 10% and 25% of female and male youth, respectively [[6]Anderson H.R. Baumburg B. Alcohol in Europe. A public health perspective. Institute of Alcohol Studies, London2006Google Scholar]. The burden of compensated alcohol cirrhosis among the general population and heavy drinkers is not well known. The development of non-invasive methods to detect significant liver fibrosis (e.g., elastography, serum markers) should help in elucidating this issue. A recent study in France indicates that alcohol abuse accounts for up to one third of liver fibrosis cases [[7]Roulot D. Costes J.L. Buyck J.F. Warzocha U. Gambier N. Czernichow S. et al.Transient elastography as a screening tool for liver fibrosis and cirrhosis in a community-based population aged over 45 years.Gut. 2010; 60: 977-984Crossref PubMed Scopus (31) Google Scholar]. The best comparative proxy for the burden of ALD is mortality from liver cirrhosis as a whole, although as discussed later this has its limitations. Mortality rates from liver cirrhosis vary considerably between European countries [[8]Zatonski W.A. Sulkowska U. Manczuk M. Rehm J. Boffetta P. Lowenfels A.B. et al.Liver cirrhosis mortality in Europe, with special attention to Central and Eastern Europe.Eur Addict Res. 2010; 16: 193-201Crossref PubMed Scopus (39) Google Scholar] with a 15-fold variation between the highest and lowest national rates [[9]Leon DA, Collier T. Trends in mortality from liver cirrhosis in Europe in EASL meeting on alcoholic liver disease. Athens: 2010.Google Scholar]. However, Europe is essentially divided into two, with Eastern European states tending to have higher rates than the others [[8]Zatonski W.A. Sulkowska U. Manczuk M. Rehm J. Boffetta P. Lowenfels A.B. et al.Liver cirrhosis mortality in Europe, with special attention to Central and Eastern Europe.Eur Addict Res. 2010; 16: 193-201Crossref PubMed Scopus (39) Google Scholar]. Time trends in liver cirrhosis mortality over the past 30 years show very heterogeneous patterns between countries. About half the countries of Europe, including Austria, France, Germany, Italy, Portugal, and Spain as well as two Eastern European countries (Hungary and Romania) have experienced sharp declines in liver cirrhosis mortality [[9]Leon DA, Collier T. Trends in mortality from liver cirrhosis in Europe in EASL meeting on alcoholic liver disease. Athens: 2010.Google Scholar], whereas the Western countries of Finland, Ireland, and the United Kingdom [[10]Leon D.A. McCambridge J. Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data.Lancet. 2006; 367: 52-56Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar], as well as a larger number of Eastern European countries including Estonia [[11]Parna K. Rahu K. Dramatic increase in alcoholic liver cirrhosis mortality in Estonia in 1992–2008.Alcohol Alcohol. 2010; 45: 548-551Crossref PubMed Scopus (10) Google Scholar], Lithuania, Poland, and Russia have increasing rates. In terms of alcohol-related hospital admissions, for example, parallel to the upward trend in liver cirrhosis mortality, general hospital admissions [[12]Thomson S.J. Westlake S. Rahman T.M. Cowan M.L. Majeed A. Maxwell J.D. et al.Chronic liver disease – an increasing problem: a study of hospital admission and mortality rates in England, 1979–2005, with particular reference to alcoholic liver disease.Alcohol Alcohol. 2008; 43: 416-422Crossref PubMed Scopus (25) Google Scholar], and admissions to intensive care units with ALD have risen sharply in the United Kingdom [[13]Welch C. Harrison D. Short A. Rowan K. The increasing burden of alcoholic liver disease on United Kingdom critical care units: secondary analysis of a high quality clinical database.J Health Serv Res Policy. 2008; 13: 40-44Crossref PubMed Scopus (9) Google Scholar]. The extent of international variation and trends in ALD is difficult to determine. Mortality data from liver disease is available for most countries, and to this extent liver cirrhosis mortality is frequently used as the indicator of choice. However, it is not possible to reliably separate out alcoholic from non-alcoholic cirrhosis mortality. In an undetermined proportion of deaths in which alcohol is the key factor, the certifying doctor may choose not to explicitly mention alcohol on the death certificate [[14]Bell G. Cremona A. Alcohol and death certification: a survey of current practice and attitudes.Br Med J (Clin Res Ed). 1987; 295: 95Crossref PubMed Google Scholar]. The extent of this bias is unknown, but it is likely to vary by country, sex, age, and era. For this reason, emphasis is usually given to analyzing mortality from liver cirrhosis regardless of whether it is specified as alcoholic or not [[15]Ramstedt M. Alcohol consumption and liver cirrhosis mortality with and without mention of alcohol – the case of Canada.Addiction. 2003; 98: 1267-1276Crossref PubMed Scopus (47) Google Scholar]. These factors, taken together, mean that at the present time our best estimates about the international variation in the burden of ALD, based on mortality from liver cirrhosis as a whole, need to be interpreted with caution. There is a clear need to perform large-scale epidemiological studies to determine the prevalence of compensated ALD in the general population and the weight of ALD as a cause of cirrhosis. European countries vary considerably in terms of per capita alcohol consumption, predominant beverage type, and the extent to which drinkers imbibe substantial quantities on single occasions (binge drinking) [[6]Anderson H.R. Baumburg B. Alcohol in Europe. A public health perspective. Institute of Alcohol Studies, London2006Google Scholar]. In order to propose a consensual definition, the National Institute of Alcohol Abuse and Alcoholism defines binge drinking episodes as consumption of five or more drinks (male) or four or more drinks (female) in the space of about 2 h [[16]Zakhari S. Li T.K. Determinants of alcohol use and abuse: impact of quantity and frequency patterns on liver disease.Hepatology. 2007; 46: 2032-2039Crossref PubMed Scopus (97) Google Scholar]. These differences in type and pattern of consumption tend to fall along an East–West divide [[17]Popova S. Rehm J. Patra J. Zatonski W. Comparing alcohol consumption in central and Eastern Europe to other European countries.Alcohol Alcohol. 2007; 42: 465-473Crossref PubMed Scopus (105) Google Scholar]. While per capita alcohol consumption is strongly correlated with liver cirrhosis mortality rates across countries [[18]Ramstedt M. Per capita alcohol consumption and liver cirrhosis mortality in 14 European countries.Addiction. 2001; 96: S19-S33Crossref PubMed Google Scholar], there remains uncertainty about whether these other dimensions of drinking behavior in a population are related to risk [19Mathurin P. Deltenre P. Effect of binge drinking on the liver: an alarming public health issue?.Gut. 2009; 58: 613-617Crossref PubMed Scopus (49) Google Scholar, 20Rehm J. Kanteres F. Lachenmeier D.W. Unrecorded consumption, quality of alcohol and health consequences.Drug Alcohol Rev. 2010; 29: 426-436Crossref PubMed Scopus (43) Google Scholar]. There are several aspects to this. Firstly, does beverage type matter above and beyond volume of ethanol consumed [[21]Gill J. Tsang C. Black H. Chick J. Can part of the health damage linked to alcohol misuse in Scotland be attributable to the type of drink and its low price (by permitting a rapid rate of consumption)? A point of view.Alcohol Alcohol. 2010; 45: 398-400Crossref PubMed Scopus (5) Google Scholar]? Secondly, does drinking to intoxication (sometimes referred to as binge drinking) confer a particular risk? Thirdly, what is the contribution to the burden of ALD induced by the consumption of substances that may contain hepatotoxic substances in addition to ethanol [20Rehm J. Kanteres F. Lachenmeier D.W. Unrecorded consumption, quality of alcohol and health consequences.Drug Alcohol Rev. 2010; 29: 426-436Crossref PubMed Scopus (43) Google Scholar, 22Lang K. Vali M. Szucs S. Adany R. McKee M. The composition of surrogate and illegal alcohol products in Estonia.Alcohol Alcohol. 2006; 41: 446-450Crossref PubMed Scopus (26) Google Scholar, 23McKee M. Suzcs S. Sarvary A. Adany R. Kiryanov N. Saburova L. et al.The composition of surrogate alcohols consumed in Russia.Alcohol Clin Exp Res. 2005; 29: 1884-1888Crossref PubMed Scopus (79) Google Scholar]? This latter class of drink includes fruit brandies, which are frequently consumed in Hungary, for example [[24]Szucs S. Sarvary A. McKee M. Adany R. Could the high level of cirrhosis in central and Eastern Europe be due partly to the quality of alcohol consumed? An exploratory investigation.Addiction. 2005; 100: 536-542Crossref PubMed Scopus (54) Google Scholar] as well as home brewed alcohols that are drunk in Russia [[25]Gil A. Polikina O. Koroleva N. McKee M. Tomkins S. Leon D.A. Availability and characteristics of nonbeverage alcohols sold in 17 Russian cities in 2007.Alcohol Clin Exp Res. 2009; 33: 79-85Crossref PubMed Scopus (40) Google Scholar] and other parts of the former Soviet Union [[26]Lachenmeier D.W. Samokhvalov A.V. Leitz J. Schoeberl K. Kuballa T. Linskiy I.V. et al.The composition of unrecorded alcohol from eastern Ukraine: is there a toxicological concern beyond ethanol alone?.Food Chem Toxicol. 2010; 48: 2842-2847Crossref PubMed Scopus (7) Google Scholar]. An important aspect of public health policy concerning alcohol has been the attempt to establish a safe threshold for consumption. This revolves primarily around the extent to which moderate alcohol consumption is cardioprotective [27Corrao G. Rubbiati L. Bagnardi V. Zambon A. Poikolainen K. Alcohol and coronary heart disease: a meta-analysis.Addiction. 2000; 95: 1505-1523Crossref PubMed Scopus (499) Google Scholar, 28Klatsky A.L. Alcohol and cardiovascular diseases.Expert Rev Cardiovasc Ther. 2009; 7: 499-506Crossref PubMed Scopus (29) Google Scholar]. This positive effect of alcohol, if real, can then offset the large array of negative health consequences of even moderate alcohol consumption. For many individual diseases such as liver cirrhosis; however, there is no a priori reason to believe a threshold effect exists, as risk appears to increase steeply with the amount of alcohol consumed. In a meta-analysis of daily consumption levels in relation to cirrhosis, patients taking 25 g of ethanol a day were at higher risk of cirrhosis than non-drinkers [[29]Corrao G. Bagnardi V. Zambon A. Torchio P. Meta-analysis of alcohol intake in relation to risk of liver cirrhosis.Alcohol Alcohol. 1998; 33: 381-392Crossref PubMed Google Scholar]. A more recent meta-analysis found increased risks of mortality from liver cirrhosis among men and women drinking 12–24 g of ethanol per day [[30]Rehm J. Taylor B. Mohapatra S. Irving H. Baliunas D. Patra J. et al.Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis.Drug Alcohol Rev. 2010; 29: 437-445Crossref PubMed Scopus (103) Google Scholar]. Indeed, among women, a significant increase was also seen for those drinking up to 12 g/day. These levels of consumption (<25 g/day) are appreciably lower than most public health recommendations for overall safe levels of consumption. The human evidence to date therefore suggests that if a threshold exists, it is very low, and may in fact be difficult to detect because of limitations in measuring consumption below 10–12 g per day. It should be noted that neither meta-analysis was able to distinguish between the effects of daily consumption from the effects of “binge” drinking. To this extent little is known about thresholds as applied to “binge” drinking. Further clinical and experimental studies are required to define the role of “binge” in the pathogenesis of ALD and the underlying mechanisms. Finally, risk of cirrhosis is almost certainly related to the length of time over which an individual has drunk regularly and not simply to the usual amount consumed. Conversely, there is some clinical evidence that cessation of drinking at any point in the natural history of the disease reduces the risks of disease progression and occurrence of complications from cirrhosis. Even though there remain uncertainties about the precise burden of and trends in ALD in Europe, there is no doubt that in many countries it is very substantial and or increasing. While improvements in treatment are essential, developing population-based policies to reduce levels of harmful and hazardous consumption are a priority. More broadly, there is increasing recognition of the heavy social, health, and economic burdens imposed by heavy alcohol drinking and the policies to reduce harm caused by alcohol, need to be urgently implemented [[31]Casswell S. Thamarangsi T. Reducing harm from alcohol: call to action.Lancet. 2009; 373: 2247-2257Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar]. Several meta-analyses have evaluated the efficacy and cost efficacy of different policy targeted areas [[32]Anderson P. Chisholm D. Fuhr D.C. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol.Lancet. 2009; 373: 2234-2246Abstract Full Text Full Text PDF PubMed Scopus (298) Google Scholar]. The most cost-effective policies are those that reduce availability of alcohol, either through the pricing policies or the hours and places of sale, as well as implementation of minimum age purchase laws. (1)Alcohol abuse is a major cause of preventable liver disease worldwide.(2)Per capita alcohol consumption is strongly correlated with liver cirrhosis mortality rates across countries. Any evidence based policy in Europe need to implement preventive measures aimed at reducing alcohol consumption at the population level.(3)The binge drinking pattern is becoming increasingly prevalent, mainly among young individuals, but its impact on liver disease is unknown. (1)Large epidemiological studies using non-invasive methods should establish the prevalence of all forms of alcoholic liver disease in the general population.(2)Studies evaluating the short and long-term impact of binge drinking in the development and severity of ALD are particularly needed. A large number of European citizens drink alcohol. Europe has the highest per capita alcohol consumption (11 L of pure alcohol per year in population ⩾15 years old). Fifteen percent of Europeans (58 million citizens) drink excessively (>40 g per day in men, and >20 g per day in women), with a higher proportion among males and young people. Alcohol abuse and alcohol dependence must be seen as different forms of the same disorder, as it is recognized in the new DSM-V draft. Alcohol abuse is not recognized as a disorder in the ICD-10, and in fact the WHO uses the terms hazardous and harmful alcohol use instead of alcohol abuse. The term ‘risky drinker’ is commonly used to define people who drink excessively. Drinking habits of patients need to be routinely screened in patients with liver diseases, and this must be done with tools that have proven its reliability [[16]Zakhari S. Li T.K. Determinants of alcohol use and abuse: impact of quantity and frequency patterns on liver disease.Hepatology. 2007; 46: 2032-2039Crossref PubMed Scopus (97) Google Scholar]. There is a common trend to measure alcohol intake in grams per day or grams per week. Calculations are usually made counting standard drink units [[33]Miller W. Heather N. Hall W. Calculating standard drink units: international comparisons.Br J Addict. 1991; 86: 43-47Crossref PubMed Google Scholar]. The content of a standard drink may differ from country to country, but in Europe most of the countries have fixed their standard drink unit to an ethanol content of 8–10 g. Even though measurements in standard drinks may lose accuracy, they are reliable, save time, and are particularly useful in busy clinical settings. Quantity-frequency questionnaires and retrospective diaries (time-line follow back) can be used to calculate patients’ drinking habits. The former are usually preferred for their simplicity, but they must include data on both working and weekend days. A good alternative to quantity frequency questionnaires is the use of screening instruments to screen risky drinking and alcohol dependence. There are many tools that have been validated and translated into many languages, but the AUDIT (Alcohol Use Disorders Inventory Test) remains the ‘gold standard’. Developed by the WHO in 1982, it has proven to have good sensitivity and specificity in clinical settings across different countries [[34]Saunders J.B. Aasland O.G. Babor T.F. de la Fuente J.R. Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption.Addiction. 1993; 88: 791-804Crossref PubMed Google Scholar]. The AUDIT has 10 questions that explore consumption (1–3), dependence (4–6), and alcohol related problems (7–10) (Table 2). There are two cut-off points, one for dependence and one for risky drinking. Shorter versions have been developed. The AUDIT C includes just the first three questions of the AUDIT and is reliable for the screening of ‘risky drinking’ [35Bush K. Kivlahan D.R. McDonell M.S. Fihn S.D. Bradley K.A. The AUDIT Alcohol Consumption Questions (AUDIT-C): an effective brief screening test for problem drinking.Arch Intern Med. 1998; 158: 1789-1795Crossref PubMed Scopus (967) Google Scholar, 36Gual A. Segura L. Contel M. Heather N. Colom J. AUDIT-3 and AUDIT-4: effectiveness of two short forms of the alcohol use disorders identification test.Alcohol Alcohol. 2002; 37: 591-596Crossref PubMed Google Scholar]. The NIAAA (National Institute of Alcohol Abuse and Alcoholism) recommends using the third question of the AUDIT (How often do you have six or more drinks in one occasion?) as a single screening question, which should be followed by the whole AUDIT in case the answer is rated positive [[16]Zakhari S. Li T.K. Determinants of alcohol use and abuse: impact of quantity and frequency patterns on liver disease.Hepatology. 2007; 46: 2032-2039Crossref PubMed Scopus (97) Google Scholar].Table 2AUDIT questionnaire [36]Gual A. Segura L. Contel M. Heather N. Colom J. AUDIT-3 and AUDIT-4: effectiveness of two short forms of the alcohol use disorders identification test.Alcohol Alcohol. 2002; 37: 591-596Crossref PubMed Google Scholar. To score the AUDIT questionnaire, sum the scores for each of the 10 questions. A total ⩾8 for men up to age 60, or ⩾4 for women, adolescents, or men over age 60 is considered a positive screening test. Open table in a new tab Alcoholics have a high psychiatric co-morbidity. In general, population surveys of alcoholics show high prevalence of anxiety disorders, affective disorders, and schizophrenia [[37]Bourdon K.H. Rae D.S. Locke B.Z. Narrow W.E. Regier D.A. Estimating the prevalence of mental disorders in US. Adults from the Epidemiologic Catchment Area Survey.Public Health Rep. 1992; 107: 663-668PubMed Google Scholar]. Anxiety and affective disorders may be independent or concurrent with alcohol dependence. Independent disorders will need specific treatment, while concurrent disorders may disappear once the patient is weaned off alcohol. Alcoholics have a higher risk of developing other addictions, including nicotine. Alcoholics tend to be heavier smokers and the treatment of nicotine dependence requires more intensive support [[38]Grant B.F. Hasin D.S. Chou S.P. Stinson F.S. Dawson D.A. Nicotine dependence and psychiatric disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions.Arch Gen Psychiatry. 2004; 61: 1107-1115Crossref PubMed Scopus (672) Google Scholar]. Alcoholics who are polydrug users are difficult to manage and should be systematically referred to specialized treatment. Data suggest that alcohol dependence appears within 5 years before the patient is referred to specialist treatment. Special attention should be paid to the coordination between hepatologists and addiction specialists (psychiatrists, psychologists, and social workers) in order to reduce the gap between the signs of alcohol dependence appearing and referral. Because cigarette smoking and alcohol abuse are synergistic in causing cardiovascular diseases and cancer, including HCC, hepatologists are encouraged to promote and assist smoking cessation among patients with ALD [[39]Altamirano J. Bataller R. Cigarette smoking and chronic liver diseases.Gut. 2010; 59: 1159-1162Crossref PubMed Scopus (23) Google Scholar]. Alcohol withdrawal syndrome (AWS) is a severe medical condition affecting alcohol-dependent patients who suddenly discontinue or decrease alcohol consumption. Light or moderate AWS usually develops within 6–24 h after the last drink and symptoms may include increase in blood pressure and pulse rate, tremors, hyperreflexia, irritability, anxiety, headache, nausea, and vomiting. These symptoms may progress to more severe forms of AWS, characterized by delirium tremens, seizures, coma, cardiac arrest, and death [[40]Fiellin D.A. O’Connor P.G. Holmboe E.S. Horwitz R.I. Risk for delirium tremens in patients with alcohol withdrawal syndrome.Subst Abuse. 2002; 23: 83-94PubMed Google Scholar]. Severity scores for AWS are potentially useful in the management of patients. However, these scores are insufficiently validated at this time, especially in the setting of ALD. Benzodiazepines are considered the ‘gold standard’ treatment for AWS, given their efficacy to reduce both withdrawal symptoms and the risk of seizures and/or delirium tremens [41Amato L. Minozzi S. Vecchi S. Davoli M. Benzodiazepines for alcohol withdrawal.Cochrane Database Syst Rev. 2010; 3: CD005063PubMed Google Scholar, 42Mayo-Smith M.F. Beecher L.H. Fischer T.L. Gorelick D.A. Guillaume J.L. Hill A. et al.Management of alcohol withdrawal delirium. An evidence-based practice guideline.Arch Intern Med. 2004; 164: 1405-1412Crossref PubMed Scopus (202) Google Scholar]. Long-acting benzodiazepines (e.g. diazepam, chlordiazepoxide) provide more protection against seizures and delirium, but short and intermediate-acting benzodiazepines (e.g. lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction [[43]McKeon A. Frye M.A. Delanty N. The alcohol withdrawal syndrome.J Neurol Neurosurg Psychiatry. 2008; 79: 854-862Crossref PubMed Scopus (94) Google Scholar]. In Europe, clomethiazole is also used to treat AWS [[44]Mayo-Smith M.F. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline.American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal; JAMA. 1997; 278: 144-151Google Scholar]. Given the side-effects of benzodiazepines in patients with advanced liver disease and potential for abuse, preliminary research has been conducted to identify new medications for AWS, such as clonidine, atenolol, carbamazepine, valproic acid, gamma-hydroxybutyrate, topiramate, baclofen, gabapentin, and pregabalin [[45]Bayard M. McIntyre J. Hill K.R. Woodside Jr., J. Alcohol withdrawal syndrome.Am J Fam Physician. 2004; 69: 1443-1450PubMed Google Scholar]. Whilst sufficient evidence in favor of their use is lacking, topiramate and baclofen have promise given their potential to be used for AWS first [46Addolorato G. Leggio L. Abenavoli L. Agabio R. Caputo F. Capristo E. et al.Baclofen in the treatment of alcohol withdrawal syndrome: a comparative study versus diazepam.Am J Med. 2006; 119: 13-18Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 47Leggio L. Kenna G. Swift R. New developments for the pharmacological treatment of alcohol withdrawal syndrome. A focus on non-benzodiazepine GABAergic medications.Prog Neuropsychopharmacol Biol Psychiatry. 2008; 32: 1106-1117Crossref PubMed Scopus (51) Google Scholar], and then to prevent relapse. Alcohol abstinence represents a critical goal in patients with ALD since abstinence improves the clinical outcomes of all stages of ALD. In the past, disulfiram was the only drug available for alcoholism. Disulfiram represents an effective alcohol pharmacotherapy [[48]Krampe H. Ehrenreich H. Supervised disulfiram as adjunct to psychotherapy in alcoholism treatment.Curr Pharm Des. 2010; 16: 2076-2090Crossref PubMed Scopus (35) Google Scholar]; however, disulfiram should be avoided in patients with severe ALD because of possible hepatotoxicity [[49]Forns X. Caballería J. Bruguera M. Salmerón J.M. Vilella A. Mas A. et al.Disulfiram-induced hepatitis. Report of four cases and review of the literature.J Hepatol. 1994; 21: 853-857Abstract Full Text PDF PubMed Scopus (28) Google Scholar]. More recently, the growing understanding of the neurobiology of alcoholism has led to the development of effective pharmacologic agents that can complement psychosocial treatments, in particular naltrexone [[50]Anton R.F. Naltrexone for the management of alcohol dependence.N Engl J Med. 2008; 359: 715-721Crossref PubMed Scopus (58) Google Scholar] and acamprosate [[51]Kiefer F. Mann K. Acamprosate: how, where, and for whom does it work? Mechanism of action, treatment targets, and ind" @default.
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