Miriam E. Tucker

April 27, 2015

VIENNA — Alcohol abuse plays a major and often underappreciated role in the morbidity associated with chronic hepatitis C infection, and can confound cost–benefit assessments of direct-acting antiviral agents, a new study suggests.

In patients with chronic hepatitis C, 88% of liver-related events or in-hospital deaths occurred in patients with chronic alcohol abuse disorders or severe comorbidities, said Michael Schwarzinger, MD, from the Translational Health Economics Network in Paris.

In patients with chronic hepatitis C, alcohol withdrawal or abstinence was associated with 29% reduction in the risk for those outcomes, compared with continued drinking, he added.

Injection drug use is the most common route of transmission of hepatitis C, and is known to be associated with a higher risk for alcohol abuse disorders.

"Back in the 1970s people were injecting drugs and boozing and didn't know about hepatitis C," Dr Schwarzinger told Medscape Medical News. "What's surprising is that, unfortunately, in many clinical studies, alcoholism isn't really measured or is not properly taken into account in analyses, although it has a significant role."

During his presentation here at the Liver Congress 2015, Dr Schwarzinger reported that singer Lou Reed was the inspiration for this study. Reed died in October 2013, shortly after liver transplantation.

 
I tried to give up drugs by drinking. Lou Reed
 

His death was attributed to liver failure related to hepatitis C, but his quote — "I tried to give up drugs by drinking" — highlights how alcohol abuse can complicate the hepatitis C picture, Dr Schwarzinger pointed out.

Lou Reed

These days, there is much discussion in the field of hepatology about the cost-effectiveness of new highly effective but extremely expensive oral direct-acting antiviral combination regimens for hepatitis C. The findings from this study suggest that the "expected value of interferon-free treatments in cost-effectiveness models is overestimated in patients without alcohol abuse disorders or severe comorbidities," he said.

"It's important to at least be aware that for patients who have no alcohol problem and no other strong comorbidities, prognosis is probably much better," he told Medscape Medical News.

But in hepatology circles, alcohol is a "sensitive topic," said Tom Hemming Karlsen, MD, from Oslo University Hospital in Norway, who moderated a news conference here at the meeting.

"This is a cultural and deeply embedded topic," he explained. Although "people know that alcohol harms the liver, they don't really have a broader understanding, like you see for heart disease." In fact, "there is a general attitude that liver disease is self-inflicted."

More information is needed to determine the effect of the alcohol issue on cost-effectiveness. "We still need data to quantify the degree of the impact," Dr Karlsen explained.

For their study, Dr Schwarzinger's team analyzed the French National Hospital Discharge Database, which included data on all public and private acute and postacute care. They identified 28,953,755 adults who had at least one hospital stay from 2008 to 2012, which constitutes about half the adults in France.

Of these hospitalized patients, 0.02% had undergone liver transplantation, 0.27% had been treated for primary liver cancer, and 1.70% had been treated for end-stage liver disease. And 1,506,453 people (5.20%) died in the hospital.

The proportion of males was higher in the 112,146 patients (0.39%) infected with hepatitis C than in uninfected patients (58% vs 42%), and mean age was higher in those infected with hepatitis C (53.0 vs. 49.7 years).

In the study cohort, about 4% of all liver-related events and about 1% of in-hospital mortality occurred in patients infected with hepatitis C.

Alcohol use disorders were more common in hepatitis C patients than in uninfected patients (20.8% vs 2.4%; odds ratio, 6.3). And the presence of one or more severe comorbidities — such as myocardial infarction, dementia, kidney disease, diabetes, and chronic pulmonary disease — was 2.4-fold more common in hepatitis C than in uninfected patients (56.2% vs 28.7%).

Of the patients infected with hepatitis C, 18.9% experienced a liver-related event and 13.5% died in the hospital.

Table. Outcomes in Patients Infected With Hepatitis C

Patient Characteristic Liver-Related Event, % In-Hospital Death, %
Alcohol use disorder 46.3 33.7
No alcohol problem, major comorbidity 39.9 57.5
No alcohol problem, no comorbidity 13.8 8.8

 

For patients infected with hepatitis C who had stopped drinking or who had been abstinent all along, there was a "very significant" 29% reduction in the risk for either a liver-related event or an in-hospital death, compared with those who continued to drink. In fact, the benefit of abstaining extended to the entire hospitalized population, with a 25% reduction in risk.

"As with any provocative results, these make you think," said session comoderator Mauro Bernardi, MD, from the University of Bologna in Italy.

"My reaction is we need to analyze this in more depth," he told Medscape Medical News.

"For the time being, I wouldn't take for granted that we should go for alcohol abuse treatment rather than hepatitis C treatment," he explained. "In reality, we have to fight both alcohol and infection."

Dr Schwarzinger is director of the Translational Health Economics Network, which funded the study. Dr Karlsen and Dr Bernardi have disclosed no relevant financial relationships.

European Association for the Study of the Liver (EASL) International Liver Congress 2015: Abstract G16. Presented April 25, 2015.

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