Patients with Liver Disease Rarely Get Alcohol Use Disorder Pharmacotherapy

Available alcohol use disorder pharmacotherapy is rarely utilized in patients with high-risk clinical history including alcohol-associated liver disease (ALD), according to an analysis of commercially insured patient data in the US.¹

A new study presented at the American College of Gastroenterology (ACG) 2024 Scientific Sessions in Philadelphia, PA, this week showed that key pharmaceutical options to treat the severity and risk of mortality in patients with alcohol use disorder are disproportionately not reaching patients with ALD or hepatic decompensation. The findings additionally found patients with high-index comorbidities, psychiatric conditions, or those at older age are significantly more likely to receive alcohol use disorder pharmacotherapy.

Investigators led by Alex R. Jones, MD, of UT Southwestern Medical Center, sought to characterize pharmacologic treatment for alcohol use disorder among US adults with commercial insurance; they additionally wanted to identify factors linked to a receipt for such therapy and discern any apparent patterns in prescribing.

The current pharmacologic armamentarium for alcohol use disorder include options like naltrexone, acamprosate, disulfiram, gabapentin, baclofen, and topiramate. These agents have been commonly associated with reduced risk of mortality and hepatic decompensation in clinical trials—necessary treatment options given the increasing rate of ALD, and therefore cirrhosis in the US.²

Jones and colleagues assessed commercial insurance data from the PharMetrics Plus for Academics to identify adult patients with alcohol use disorder—defined as ≥2 outpatient or ≥1 inpatient diagnostic codes—in the time period of 2006 – 2021. The team sought a primary outcome of receipt of pharmacotherapy for the disorder any time following diagnosis; multivariable logistic regression analyses were conducted to identify any factors inked to receipt of therapy.¹

The analysis identified 28,625 adult patients with alcohol use disorder. Among them, 1201 (4.2%) were diagnosed with ALD cirrhosis and 439 (1.5%) were diagnosed with acute alcohol-associated hepatitis. The remaining 26,985 (94.3%) had no ALDs.

Patients who received alcohol use disorder pharmacotherapy were generally older per median age (45 years vs 42 years; P <.001). They were primarily male (64.5%) and were diagnosed with a psychiatric condition other than substance disorder (45.9%). Another one-third (35.7%) did have a non-alcoholic substance use disorder as well.

Investigators found that 15% of all patients with non-ALD alcohol use disorder received a pharmacotherapy during the observed time period. Comparatively, only 2.0% of patients with ALD cirrhosis and 10.0% of patients with alcohol-associated hepatitis from the same cohort received such a prescription. Even one-time prescription rates were higher for patients without ALD (28.4%) than those with ALD cirrhosis (10.7%)

Median time to alcohol use disorder treatment prescription for patients without ALD was 301 days (IQR, 45 – 879). The median wait time was even greater for patients with ALD cirrhosis (334.5; IQR, 36.25 – 441.5) and alcohol-associated hepatitis (367; IQR, 66.5 – 852.5; P = .51).

The most commonly prescribed medications to all patients with alcohol use disorder were gabapentin (n = 2695 [9.4%]), combination therapy (n = 866 [3.0%]), oral naltrexone (n = 756 [2.6%]), and topiramate (n = 579 [2.0%]).

Investigators noted that each of psychiatric comorbidity (adjusted odds ratio [aOR], 2.76; 95% CI, 2.56 – 2.98) and Charlson Comorbidity Index scores of ≥3 (aOR, 2.21; 95% CI, 1.80 – 2.71) were linked to a more than 2-fold increased odds of patients receiving alcohol use disorder pharmacotherapy. Patients being ≥50 years old was associated with a 33% increased likelihood of receiving pharmacotherapy (aOR, 1.33; 95% CI, 1.23 – 1.43), and female sex was associated with a 31% increased likelihood (aOR, 1.31; 95% CI, 1.22 – 1.41).

Adversely, ALD cirrhosis (aOR, 0.24; 95% CI, 0.16 – 0.35) and hepatic decompensation (aOR, 0.08; 95% CI, 0.03 – 0.17) were associated with significantly decreased likelihood of pharmacotherapy.

Though the trial was limited due to the utility of commercial insurance data and a lack of demographic details in the patient population, investigators concluded the findings show alcohol use disorder pharmacotherapy is provided to few patients with ALD—and the wait for those who do receive it is significantly delayed.

“In a large nationally representative cohort of commercially insured patients, AUD pharmacotherapy was underutilized in at risk populations, especially patients with ALD, among whom just 1 in 50 received AUD therapy,” investigators wrote. “Providers caring for patients with ALD should consider this underutilized therapy, or refer for psychiatric consultation when appropriate.”

References

1. ^{Jones AR, Jiang Y, Tadros MM, Bardhi O, et al. Pharmacologic Therapy for Alcohol Use Disorder Is Under-Utilized in Alcohol-Associated Liver Disease Among Commercially Insured U.S. Adults. Abstract presented at: American College of Gastroenterology (ACG) 2024 Scientific Sessions. Philadelphia, PA. October 25 – 30, 2024.}
2. ^{Kunzmann K. Relentless: The Concurrent Alcohol Abuse, Liver Disease Epidemics in the US. HCPLive. Published October 3, 2023. https://www.hcplive.com/view/concurrent-alcohol-abuse-liver-disease-epidemics-us}