S2915 Pharmacologic Therapy for Alcohol Use Disorder After Liver Transplantation for Alcohol-Associated Liver Disease: A Retrospective Analysis

Introduction: Alcohol relapse (AR) following liver transplantation (LT) is associated with adverse outcomes including graft loss and mortality. Pharmacologic therapy (PT) for alcohol use disorder (AUD) is an effective treatment, but is frequently underutilized after LT. We studied the use and timing of PT initiation for AUD in LT recipients (LTRs) with alcohol-associated liver disease (ALD). Methods: We conducted a retrospective study of LTRs with ALD at a single large LT center between January 1, 2016 and November 30, 2023. AR was identified via patient self-report or by biochemical markers including phosphatidylethanol (PETH), serum ethanol, or urine ethyl glucuronide. Sustained alcohol use at relapse was defined as >100 days of alcohol use. Harmful use was defined as >4 drinks/day or >14 drinks/week for men, >3 drinks/day or >7 drinks/week for women, or a PETH level >200. Medication lists were reviewed for PT commonly used to treat AUD including naltrexone, acamprosate, and baclofen along with dates of initiation. Results: Among 383 LTRs, only 28 (7.3%) were started on PT after LT. Of those ultimately started on PT, only 3 (10.7%) were started on treatment prior to any AR while the others (89.3%) started on PT after AR occurred. Eighty LTRs experienced AR (mean age 53 ± 7, 75.5% man), of whom 27 (33.8%) received PT for AUD. Among LTRs who relapsed and received PT, 96% had sustained alcohol use, 81% harmful alcohol use, and 63% developed recurrent ALD compared to 68%, 62.2%, and 37.7%, respectively, of LTRs who relapsed that were not started on PT. The median time from date of relapse to initiation of PT in LTRs with AR was 271 days (IQR 55-610). Two LTRs in this group received PT prior to AR, only 2 were started on PT the day AR was identified, while the others experienced a delay in initiation of PT ranging from 4 to 1064 days. Conclusion: The number of LTRs started on PT for AUD after LT is very low, even among those who developed AR. Among LTRs who experienced AR, the rates of sustained alcohol use, harmful alcohol use, and recurrent ALD were higher in those who received PT compared to those who did not. Patients who were eventually started on PT represented a higher-risk group with more severe patterns of AR. Moreover, in this group, there was significant delay from the time of relapse to the initiation of PT. Our findings suggest that pharmacologic therapy for AUD after LT is used infrequently, and when used, is started too late.