Liver disease in community drug and alcohol services

In this Hep C U Later guest blog, Dr Rachel Turner, a GPwSI from Inclusion (part of Midlands Partnership University NHS Foundation Trust) takes us on a tour of liver disease, and some of the potential routes community drug and alcohol services can take to improve it.

 

Our mission, should we choose to accept it, is to prevent liver disease and detect liver disease early so that we can slow it down or put it into reverse. And accept this mission we must because deaths from liver disease are on the increase and have been steadily increasing over the past 50 years despite many advances in modern medicine that have caused reductions in deaths from other conditions. Approximately 10,000 people a year die of liver disease in the UK. There has been a fourfold increase in the past 50 years.

The bad news is that liver disease is a silent killer and the damage can be done undetected for years. The liver is a very forgiving organ … until it isn’t and many people do not know they are at risk.

The most common causes of liver disease are 1. alcohol-related 2. Metabolic dysfunction-associated steatotic liver disease (MASLD) which is associated with obesity and conditions like type 2 Diabetes (although you can have had MASLD without diabetes) and 3. Viral hepatitis. There are also non-preventable causes such as auto-immune liver disease.

The good news is that 9 out 10 cases of liver disease are preventable. This gives us an incredible opportunity to make a massive improvement in the health of our nation.

Let’s start with alcohol-related disease (which is the most common cause of liver disease, the burden of disease related to alcohol dwarfing that of the other two main causes). The challenge here is to ask the right questions as many people will not volunteer their drinking pattern history in primary care consultations for a variety of complex reasons related to stigma and societal norms and expectations. As clinicians we need to be more curious, more compassionate and more competent when it comes to early identification on alcohol-use disorders. The other challenge is the availability of fibroscanning or transient elastography. The 2016 NICE guideline (Cirrhosis in over 16s: assessment and management. London: NICE; 2016. NG50) recommended that ‘men who drink >50 units of alcohol per week and women who drink >35 units of alcohol per week and have done so for several months’ should be offered a fibroscan. This is regardless of what the blood tests show. It is clear to me, looking at the referrals we receive in drug and alcohol services that this is not happening. This seems to be, in part, a resource issue as not all primary care networks have access to fibroscanning and referring all these patients would overwhelm secondary care consultants. In Inclusion we have some fibroscanners which were originally purchased for screening our Hep C population but as more staff go through training we should hopefully be part of the fibroscanning army that is required to get through the huge numbers that are out there drinking harmful levels.  The problem with relying on blood tests is that they can be completely normal when significant damage is being or has been done. So, a huge number of people are going ‘under the radar’ or rather ‘dodging the fibroscanner’!

Next, MAFLD. The NICE guideline for this (National Institute for Health and Care Excellence. Non-alcoholic fatty liver disease (NAFLD): assessment and management. London: NICE; 2016. NG49) recommends the use of the ELF test (enhanced liver fibrosis test) if there is a blood test finding of abnormal LFTs (ALT predominant), or an incidental finding of fatty liver on an Ultrasound scan. If the ELF test is 10.51 or more they should be offered fibroscanning and if <10.51 it should be repeated every 3 years for adults and every 2 years for children. All these patients should be offered lifestyle advice (and appropriate treatment of associated conditions).

In both cases, the fibroscan results will determine hepatology referral.

It is worth mentioning that not all abnormal liver blood tests have a ‘hepatitic’ (ALT dominant) picture. Those with a predominantly raised ALP are ‘cholestatic’ meaning they may have obstruction related to gallstone pathology or other reasons and they may require other investigations such as Ultrasound/CT/MRI etc. There are also other, non-liver causes for raised ALP such as bone cancer or Vitamin D deficiency. It is also important to remember that there are red flags to watch out which may lead to urgent referral to hospital such as jaundice, weight loss, or ALT>500 or other intercurrent illness/infection or recent changes in medication.

Lastly, viral hepatitis. Hepatitis A (water-borne) is rare in the UK and more of a travel-related illness so discussions regarding vaccination for this prior to travel to high-risk areas is the mainstay of prevention. For the blood-borne hepatitis viruses such as Hep B and C we need pro-active case-finding for both and vaccination against Hep B. This is already happening all over the country as we can screen at risk people with a simple finger-prick test.

In the UK Hep B is most likely to be found in babies of mums who are infected so we now screen pregnant women for Hep B so this can be prevented and the baby can be born without picking up the virus. If the mother was born or grew up outside the UK in Africa, Asia, Central or South America and several other high risk countries there is a high risk of Hep B. Otherwise UK is a low risk country for Hep B. We have effective vaccination programmes for Hep B, offered to those at risk through travel, occupational or lifestyle exposure (including people who use drugs and sex-workers). In terms of treatment, Hep B cannot be cured but it can be controlled and so people who are found to have the virus are referred to hepatology for follow-up.  Most of the viral hepatitis in the UK is Hep C for which we have very effective treatments but no vaccine. Without treatment Hep C can lead to cirrhosis and a risk of liver cancer down the line. Both Hep B and C can be picked up by sharing needles/equipment for injecting drugs, sharing pipes for smoking, notes or straws for snorting, and sharing things like razors/toothbrushes with someone who has the virus. Needlestick injuries or tattoos done with used needles can also be a risk as can unprotected sexual intercourse (without the use of a barrier method).

For blood-borne hepatitis viruses, pro-active case-finding is essential because of the ‘silent’ damage that can be done as initial infection is usually asymptomatic or subclinical. Those we detect will be offered treatment (to control, Hep B or cure for Hep C) and fibroscan surveillance.

So, moving forward what’s on the cards for community drug and alcohol services?  Among the many challenges and improvements we can make is increasing our focus further on preventing liver disease, and identifying risk of liver disease early. The increasing use of fibroscans and raising awareness will help us make a big impact, ultimately preventing ill health and saving lives.

 A guest blog by Dr. Rachel Turner