Clinical question: Is naltrexone hepatically safe for the treatment of alcohol use disorder (AUD) in patients with and without liver disease?
Background: Treatment of underlying AUD can prevent and potentially reverse alcohol-associated liver disease. Given naltrexone’s warning of hepatotoxicity, there is an ongoing underutilization of pharmacologic treatments for AUD. Despite small previous studies showing no rise of transaminases with naltrexone use, the data is limited, especially for patients with underlying liver disease.
Study Design: Retrospective cohort study
Setting: Large safety-net hospital, May 2015 to November 2019
Synopsis: The study followed 160 patients who were prescribed naltrexone for AUD. They were separated into two primary groups, those with liver disease (n=100) and those without (n=60). For those with liver disease, almost half had evidence of cirrhosis (n=47) (defined by ICD-10 code or by a composite of fibrosis score, imaging, portal hypertension, international normalized ratio, and thrombocytopenia). Of those 47 patients with cirrhosis, 22 were considered decompensated. Differences in aspartate transaminase (AST), alanine aminotransaminase (ALT), alkaline phosphatase, and total bilirubin were measured before, during, and after naltrexone treatment.
Among patients with liver disease, AST, ALT, and total bilirubin improved while on naltrexone. For patients without liver disease, no significant differences in mean ALT or AST were observed. Of 160 treated patients, three cases of liver enzyme elevations occurred (1.2 events [95% CI] per 1,000 persons per year).
Limitations to this include the timing of lab draws. Only patients with labs obtained during the three interval assessments were included. In addition, patients with liver disease not on naltrexone were not included for comparison. Generalizability is limited as this study’s cohort was composed mostly of Hispanic men living in an underserved area.
Bottom line: Naltrexone for AUD is safe to use in patients with and without liver disease as demonstrated by an overall reduction in liver enzymes.
Reference: Ayyala, D, et al. Naltrexone for alcohol use disorder: hepatic safety in patients with and without liver disease. Hepatol Commun. 2022;6(12):3433-42.
Dr. Hoang is an academic hospitalist at Richmond Veterans Affairs Medical Center, and an assistant professor of medicine at Virginia Commonwealth University in Richmond, Va.