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Reply to "Treatment of alcohol use disorders in patients with liver disease".
No full textRefers To
Alain Braillon
Treatment of alcohol use disorders in patients with liver disease
Journal of Hepatology, Volume 65, Issue 6, December 2016, Page 1270
PDF (169 K)
Giovanni Addolorato, Antonio Mirijello, Pablo Barrio, Antoni Gual
Treatment of alcohol use disorders in patients with alcoholic liver disease
Journal of Hepatology, Volume 65, Issue 3, September 2016, Pages 618-630
PDF (801 K)
To the Editor:
We appreciated the interest by Braillon in our review paper on the treatment of alcohol use disorders (AUDs) in patients with alcoholic liver disease (ALD) [1]; the comments by Braillon focused on nalmefene.
The aim of our review was to provide a comprehensive and balanced update on the treatment of AUDs by discussing behavioral, psychosocial and pharmacological strategies.
In his comments, Braillon reports that the information “nalmefene is effective to reduce heavy drinking in AUDs patients” is a mischaracterisation of the data. We do not agree with this information, since nalmefene was recently approved in Europe on the basis of 3 RCT in which 1997 AUD patients were randomized (ESENSE 1, 604 patients; ESENSE 2, 718 patients, SENSE, 675 patients) [2], [3] and [4]. With respect to placebo, the drug was effective in reducing the number of heavy drinking days and the total alcohol consumption [2], [3] and [4]. For these reason this drug was approved to reduce alcohol consumption in adults with alcohol dependence in the European Union by the European Medical Agency in 2013 with a reimbursement policy variable in the different countries.
In our review [1] a particular emphasis has been given to those treatments available for patients with comorbid ALD. Under these circumstances, differences in terms of medical management, psychosocial and pharmacological interventions (both for alcohol withdrawal syndrome and alcohol relapse prevention) have been highlighted. In this case we totally agree with Braillon on the absence of data on the efficacy and safety of nalmefene in patients with liver disease; for this reason, we did not include this drug among the medications effective and safe in this subset of patients. In particular, the need for total alcohol abstinence in AUD patients, especially for those with comorbid ALD, as underlined in our paper [1], prevents the use of a drug approved for reduction of alcohol intake and not for alcohol abstinence.
As correctly commented by Dr. Braillon, the choice of the most appropriate treatment remains a decision of the physician who manages the patients and knows his clinical status and comorbidities. However, it should be emphasised that one of the main problems in the field is that few medications are available for the treatment of AUD and that the approved ones are prescribed to a minority of patients [5] and [6]
Alcoholic Hepatitis and Liver Transplantation: The Good News and What to Do about It
Full text linkNo abstract availabl
Tolerance to baclofen’s sedative effect in alcohol addicted patients: no dissipation after a period of abstinence.
No full textWe read with great interest the recent report by Besheer
et al. (2004) about the effects of GABA B
receptor agonists on parameters of alcohol self-administration in ethanol-naive and self-administering mice. Confirming previous
preclinical studies (Colombo et al. 2000,2002), the
authors showed that baclofen was able to decrease alcohol
intake in pretreated animals, reducing ethanol-reinforced
responding at doses that did not alter water-reinforced
responding. Moreover, the authors showed that ethanol-
experienced mice were less sensitive to the sedative
properties of baclofen than naive mice, suggesting that the
combination of baclofen and alcohol or baclofen alone
would have less of a negative impact on alcoholic patients
than on naive drinker subjects; this observation underlines
further the safety of the drug in the treatment of alcohol
addiction. However, the authors claim to show evidence
for the permanence of cross-tolerance to the agonist after a
period of alcohol abstinence, although no data are at
present available. Our clinical experience, correctly quoted
by the authors (Addolorato et al.2000,2002a), are in line
with the data by Besheer et al. (2004)
Progetto dal titolo “A double-blind randomized study on alcohol intake and craving reduction in alcohol-dependent patients comparing bacoflen 10mg, bacoflen 20 mg and placebo
No full textSafety and efficacy of baclofen in the treatment of alcohol-dependent patients.
No full textPreclinical studies show that antagonism of the GABA(B) receptor may represent an effective neuropharmacological approach to treat alcohol dependence. Consistent with preclinical evidence, the majority of the human studies have demonstrated that the prototype GABA(B) receptor antagonist baclofen may represent an effective mediation to treat alcohol-dependent individuals. Specifically, baclofen has shown to reduce alcohol withdrawal symptoms, as well as to reduce alcohol craving and intake, and to promote alcohol abstinence. Notably, baclofen has shown a safe profile when administered to alcoholics, including those with liver cirrhosis. In summary, baclofen represents a safe and effective medication to treat alcohol dependence, thus holding promise as a new pharmacotherapy. However, large studies are needed to confirm the present findings
Alcohol addiction: toward a patient-oriented pharmacological treatment
No full textVery few medications (i.e., disulfiram, naltrexone and acamprosate) are approved for the treatment of alcoholism and their effects are suboptimal. The development of new effective and safe pharmacological agents to treat alcoholic patients is crucial, together with the need to identify predictors of outcomes in different subsets of patients
Alcohol-Associated Liver Disease: Integrated Management With Alcohol Use Disorder
No full textAlcohol-associated liver disease (ALD) is the most common cause of cirrhosis and liver-related mortality in many regions worldwide. Around 75% of patients with cirrhosis are unaware of their disease until they are referred to the emergency department. An innovative, noninvasive screening approach is required for an earlier diagnosis of liver fibrosis. In patients with ALD the physician is inevitably dealing with 2 major disorders: the liver disease itself and the alcohol use disorder (AUD). Focus only on the liver disease will inevitably lead to failure because transient improvements in liver function are rapidly overturned if the patient returns to alcohol consumption. For this reason, integrated models of care provided by hepatologists and addiction specialists are an effective approach, which are, however, not widely available. There are multiple pharmacologic and non-pharmacologic therapies for AUD. Progress has recently been made in the management of patients with severe AH who have improved survival through better understanding of the concept of response to medical treatment, improved survival prediction, and the advent of early liver transplantation. The emerging concept is that listing for transplantation a patient with severe ALD could lead to adjusting the duration of abstinence according to the severity and evolution of liver dysfunction and the patient's addictive profile
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