Patients with cirrhosis, regardless of etiology, should not drink any alcohol at all.

Key concepts

• Any form of chronic liver disease can lead to cirrhosis - including alcoholic liver disease, hepatitis C virus, hepatitis B virus, non-alcoholic fatty liver, and many more
• For people with liver disease who have not developed cirrhosis, the use of alcohol accelerates liver injury (fibrosis) and is associated with an increased risk of developing cirrhosis
• For people with cirrhosis of any etiology, drinking alcohol can cause alcoholic hepatitis, which can precipitate acute-on-chronic liver failure (multisystem organ failure with high mortality rate)
• Cirrhotic patients with active alcohol use are usually not eligible for liver transplantation
• There is no safe amount of alcohol that can be consumed by patients with cirrhosis

Key recommendations

• Recommend complete abstinence in all patients with cirrhosis
• Assess alcohol use in all patients with cirrhosis using a nonconfrontational approach
• Discuss implications of active alcohol use in patients with cirrhosis: risk of liver decompensation and contraindication to liver transplantation

Use Clinical Tools to Help Reduce Alcohol Use in Patients with Cirrhosis

• The AUDIT-C screening tool can be helpful in identifying patients who would benefit from further evaluation for alcohol use disorder
  
• Patients can self-monitor and decrease their alcohol consumption using a drinking diary/change plan wallet card
  
• When trying to help patients reduce their alcohol use, consider motivational interviewing and brief intervention
  
• Tools for reducing alcohol use in patients with hepatitis C apply to clinical care for all patients with chronic liver disease, regardless of etiology; these tools include the Brief Intervention Teaching Guide
  

The Potential Benefits of Abstinence for Patients with Alcoholic Cirrhosis

• Abstinence improves liver function in patients with alcoholic cirrhosis
• In patients with alcoholic cirrhosis, continuous alcohol use increases the risk of further decompensation, but sustained abstinence can improve liver function
• Abstinence is the most effective therapy to decrease the risk of further liver damage
• Patients with decompensated alcoholic cirrhosis (ascites, encephalopathy, variceal bleeding) can return to a compensated status if they stop drinking

References

ACG Clinical Guideline: Alcoholic Liver Disease. Am J Gastroenterol. 2018 Feb;113(2):175-194.

EASL Clinical Practice Guidelines: Management of alcohol-related liver disease. J Hepatol. 2018 Jul;69(1):154-181.