About 14% of patients with chronic liver disease have combined alcohol abuse and HCV, and one-third of alcoholics with clinical symptoms of liver disease have been infected with HCV, which is four times the rate of HCV infection found in alcoholics who do not have liver disease[13
]. Prevalence of HCV amongst patients with AH varies from 8% to 22.2%[16
] and varies dependent on geographical areas and explains variation in the prevalence rates in our survey.
There was a lack of consensus on the outcome of AH in the presence of HCV infection. Our initial retrospective study showed HCV to be a strong predictor of mortality at 6 mo amongst AH patients[29
]. These data have been confirmed using larger VA and Nationwide Inpatient Sample databases showing higher in-hospital mortality amongst HCV infected AH patients compared to AH patients without HCV infection[30
]. Studies are suggested looking at the improvement of existing scoring systems with incorporation of HCV into the model. Further, with the availability of non-interferon based regimens for treatment of HCV infection, it would be worthwhile assessing feasibility of these options to improve outcome of HCV infected AH patients.
We found in a previous study that patients with concomitant AH and HCV received specific treatment for AH less often compared with patients with AH alone for all the patients (28% vs
= 0.014) and for severe disease (41% vs
]. This is also reflected by our survey where only 3% would chose corticosteroids for treating AH in the presence of HCV infection in contrast to 38% choosing this option for treating AH in general. The presence of HCV infection is not considered a contraindication for using steroids[35
], and fear of using corticosteroids may be based on possible harmful effect of corticosteroids on the HCV replication[36
]. An in vitro
study showed lack of effect of steroids on the HCV RNA level[42
]. Data in HCV transplanted patients have shown association of steroids use with risk for increased recurrence, worse disease, and progression of fibrosis[43
]. However, these effects are seen with bolus doses used for treatment of acute cellular rejection or when steroids are rapidly tapered after using them for long duration (6 mo or more)[44
]. In AH, steroids are used for a short period of 1 mo with slow taper later. Randomized studies are suggested comparing slow to rapid taper of steroids on the HCV RNA level and clinical outcomes.
Similar confusion and lack of consensus was also seen when choosing Pentoxifylline, a drug with excellent safety profile. Pentoxifylline has been used on long-term basis in cirrhotics including those with HCV cirrhosis[45
]. Not only, the drug was found to be safe but was also beneficial for reducing the liver disease complications especially hepatorenal syndrome[46
]. This is reflected by the 27% of the surveyed clinician who chose Pentoxifylline as a treatment option although there was general consensus that HCV does not affect AH treatment response.
To the best of our knowledge, this is the first study addressing current management of concurrent AH and HCV infection. Another strength of the study is limiting survey to gastroenterologists and hematologists who are usually involved to make decisions on management of severe AH. Lack of availability of data on gender and geographical area of respondents limited evaluation of these variables in the survey. Another limitation is keeping the survey anonymous which did not allow us to administer the survey again to check for reliability of the answers. However, this helped us to increase the response rate. Finally, some respondents did not answer to some of the questions and could have resulted in selection or non-response bias. However, we think that missing answers could be due to lack of sufficient AH population in clinical practices of respondents such as in China where HBV is endemic and or Middle East and Saudi Arabia where alcohol is not often used due to religious reasons. There is no minimum acceptable response rate in a survey[49
]. But we feel that 27% of response rate from a randomly selected group of gastroenterologists and hepatologists is adequate for the study results and avoid non-response bias.
In summary, our study showed a dissociated opinion amongst gastroenterologists and hepatologists on management of AH in the presence of concomitant HCV infection especially on the choice of drug and outcome of AH. Our findings suggest a clear need for studies to assess the response to treatment with corticosteroids amongst HCV infected AH patients and compare to AH patients without HCV infection in order to develop guidelines for management of AH patients who are also infected with HCV.