Reply to "Treatment of alcohol use disorders in patients with liver disease".

Refers 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].