Resumo do NICE
As recomendações neste tópico do Best Practice são baseadas em diretrizes internacionais autorizadas, complementadas por evidências e opiniões de especialistas relevantes para a prática recentes. Para seu maior benefício resumimos abaixo as principais recomendações das diretrizes do NICE relevantes.
Principais recomendações do NICE sobre diagnóstico
This summary covers alcohol-related liver disease in adults.
Exclude alternative causes of liver disease in people with a history of harmful or hazardous drinking who have abnormal liver blood test results. The NICE guideline defines:[164]
Harmful (high-risk) drinking as a pattern of alcohol consumption causing mental or physical damage (≥35 units per week for women; ≥50 units per week for men)
Hazardous (increasing risk) drinking as a pattern of alcohol consumption that increases someone’s risk of harm (>14 units per week for women and men [but under the thresholds for harmful drinking]).
Refer people to a specialist experienced in the management of alcohol-related liver disease to confirm a clinical diagnosis of alcohol-related liver disease.[164]
Liver biopsy should be considered for the investigation of alcohol-related liver disease, and to confirm suspected acute alcohol-related hepatitis if the hepatitis is severe enough to require corticosteroid treatment.[164]
Liver biopsy carries small but definite risks of morbidity and mortality; benefits and risks should be discussed with the person, and informed consent obtained.[164]
Diagnosis of alcohol-related cirrhosis
Be aware that there is an increased risk of cirrhosis in people who misuse alcohol.[12]
The accuracy, limitations and risks of diagnostic tests for cirrhosis should be discussed with the person. Tests should be interpreted by a professional trained to do so.[12]
Transient elastography should be offered to diagnose cirrhosis in:[12]
People diagnosed with alcohol-related liver disease
Men and people registered male at birth who drink >50 units of alcohol per week (and have done so for several months)
Women and people registered female at birth who drink >35 units of alcohol per week (and have done so for several months).
Liver biopsy should be considered if transient elastography is not suitable.[12]
Do not use routine laboratory liver blood tests to rule out cirrhosis.[12]
Refer people diagnosed with cirrhosis to a specialist in hepatology.[12]
Retesting for cirrhosis should be offered every 2 years for people with alcohol-related liver disease.[12]
Link para a orientação do NICE
Alcohol-use disorders: diagnosis and management of physical complications (CG100) April 2017. https://www.nice.org.uk/guidance/cg100
Cirrhosis in over 16s: assessment and management (NG50) September 2023. https://www.nice.org.uk/guidance/ng50
Principais recomendações do NICE sobre tratamento
Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information when prescribing.
Be aware of acute alcohol withdrawal, which can occur following sudden reduction in alcohol intake in a person who has been drinking excessively for a prolonged period of time. See the NICE guideline for management of acute alcohol withdrawal.[164]
Advise people with alcohol dependence (defined in the NICE guideline as a cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol and difficulties in controlling its use) who are not admitted to hospital to avoid a sudden reduction in alcohol intake (which can result in severe withdrawal), and offer information about how to contact local alcohol support services.[164]
Offer thiamine to people at high risk of developing, or with suspected, Wernicke's encephalopathy. See the NICE guideline for more information.[164]
People with decompensated liver disease (liver disease complicated by jaundice, ascites, variceal bleeding or hepatic encephalopathy) should be referred to be considered for assessment for liver transplantation if they still have decompensated liver disease after best management and 3 months of alcohol abstinence and are otherwise suitable candidates for liver transplantation.[164]
Management of alcohol-related hepatitis
Corticosteroid treatment should be offered to people with severe alcohol-related hepatitis and a Maddrey’s discriminant function of ≥32, only after effectively treating any active infection or gastrointestinal bleeding, controlling any renal impairment, and discussing the potential benefits and risks with the person.[164]
Maddrey’s discriminant function is used to predict prognosis in alcohol-related hepatitis and identify people suitable for steroid treatment.[164]
Corticosteroid treatment has been shown to:[164]
Improve survival in the short term (1 month) but not survival over a longer term (3 months to 1 year)
Increase risk of serious infections within the first 3 months of treatment.
The nutritional requirements of people with acute alcohol-related hepatitis should be assessed and nutritional support offered if needed, with consideration of nasogastric tube feeding.[164]
Management of cirrhosis
People who have, or are at high risk of, complications of cirrhosis should be referred to a specialist hepatology centre.[12]
The Model for End-Stage Liver Disease (MELD) score should be calculated every 6 months for people with compensated cirrhosis. A score ≥12 should be considered for use as an indicator that the person is at high risk of cirrhosis complications.[12]
Ultrasound (+/- measurement of serum alpha-fetoprotein) should be offered every 6 months as surveillance for hepatocellular carcinoma for people with cirrhosis without hepatitis B virus infection. Do not offer surveillance for people who are receiving end of life care.[12]
For people with cirrhosis and hepatitis B virus infection, see the section on surveillance testing in the NICE guideline Hepatitis B (chronic): diagnosis and management (CG165).[12]
After a diagnosis of cirrhosis, an upper gastrointestinal endoscopy should be offered to detect oesophageal varices unless the person is planning to take carvedilol or propranolol to prevent decompensation.[12]
Surveillance using upper gastrointestinal endoscopy should be offered every 3 years to people who have already had an endoscopy showing no oesophageal varices and are not taking carvedilol or propranolol.[12]
If medium or large varices are detected during endoscopy, simultaneous endoscopic variceal band ligation should be considered.[12]
See the NICE guideline for more information on management of complications of cirrhosis. Treatments that may be used to manage complications in selected people with cirrhosis include:[12]
Carvedilol or propranolol for primary prevention of decompensation
Carvedilol or propranolol or endoscopic variceal band ligation for prevention of bleeding from medium or large oesophageal varices
Prophylactic antibiotics for prevention of spontaneous bacterial peritonitis or for upper gastrointestinal bleeding
Transjugular intrahepatic portosystemic stent insertion (TIPS) procedure for refractory ascites.
© NICE (2017) (2023) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Link para a orientação do NICE
Alcohol-use disorders: diagnosis and management of physical complications (CG100) April 2017. https://www.nice.org.uk/guidance/cg100
Cirrhosis in over 16s: assessment and management (NG50) September 2023. https://www.nice.org.uk/guidance/ng50
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