Alcoholic liver disease (ALD) and its complications account for the majority of the deaths in the Western world. But there is still a lack of treatment modalities for both alcoholic steatohepatitis (ASH; the major inflammatory complication of ALD) and alcoholic liver cirrhosis. 

Severe ASH has a direct link with high mortality. Glucocorticoid treatment has been shown to improve survival, but meta-analyses of clinical trials still dont support this statement. 

Recent studies on ASH focus on cytokines, with numerous proinflammatory cytokines, like tumor necrosis factor (TNF), to have a crucial role in the pathophysiology of ALD and its complications. 

Pilot studies on using anti-TNF drugs, like pentoxifylline or infliximab, in the treatment of ASH have shown some encouraging results. 

The treatment of patients with alcohol-related cirrhosis remains symptomatic and there is a lack of accurate therapy except for orthotopic liver transplantation for end-stage liver disease. Abstinence from alcohol remains the cornerstone of management, irrespective of the stage of the disease. New treatment modalities are urgently warranted.

Key Points

• Severe alcoholic steatohepatitis (ASH), a major complication of advanced alcoholic liver disease (ALD), is associated with a high mortality rate, despite treatment with corticosteroids
• The role of reactive oxygen species has been established in the pathophysiology of ALD and ASH, but antioxidants render no benefit in the treatment of patients with ASH.
• Proinflammatory cytokines play a crucial role in the pathophysiology of ASH and ALD by mediating a majority of the inflammatory aspects of this disorder.
•  Antagonism of proinflammatory cytokines like tumor necrosis factor (TNF), by specific anti-TNF antibodies or other treatment strategies that specifically target TNF are the newer treatment modalities for ASH.
• Propylthiouracil and S-adenosyl methionine might benefit alcoholic cirrhosis, but they demand further randomized controlled trials for their use.
• Liver transplantation remains an effective therapy for patients with advanced alcoholic cirrhosis who did not recover after a period of abstinence.

SOURCE- Tilg H, Day C. Management strategies in alcoholic liver disease. Nat Rev Gastroenterol Hepatol,2007; 4: 24–34. https://doi.org/10.1038/ncpgasthep0683