People with NAFLD also drink alcohol - how should we advise and manage this expanding group in primary care? A systematic review.

Problem

Liver disease incidence, morbidity and mortality is increasing in the UK. Most liver disease is lifestyle related with alcohol related liver disease and non-alcoholic fatty liver disease (NAFLD) accounting for the majority of chronic liver disease in the UK. Traditionally, little attention has been paid to people drinking alcohol at above modest recommended limits who also have NAFLD. The incidence of obesity and diabetes is rising and the percentage of the population drinking at above recommended limits is significant.There is little guidance available on how to advise patients with a diagnosis of NAFLD around safe alcohol consumption. Interest in the relevance and implications of this ‘dual’ pathology has led to the publication of several recent reviews, each with different questions, remit and methodology, but all looking to elucidate the role of moderate alcohol consumption in the NAFLD disease process. The purpose of this systematic review is to synthesise the evidence around the role of moderate alcohol consumption in influencing progression to severe liver disease in those with NAFLD. This will help guide those working in primary care to advise and manage patients with NAFLD who also drink alcohol.

Approach

Studies were included if they were looking at the role of moderate alcohol in influencing progression to severe liver disease in those with diagnosed NAFLD.We searched the following electronic bibliographic databases: MEDLINE, EMBASE and The Cochrane Library and clinical trials.gov. We also searched for additional grey literature on CPCI-S (Conference Proceedings Citation Index – Science, Web of Knowledge) and OpenGrey (http://www.opengrey.eu/). There were no language restrictions. Titles and/or abstracts of studies were screened independently by two review authors to identify studies that potentially met the inclusion criteria outlined above. The full text of these potentially eligible studies were retrieved and independently assessed for eligibility by two review team members.

Findings

The searches identified 3780 unique references. Of the titles and abstracts screened 85 were selected for full text screening. At the time of abstract submission full texts were being assessed for inclusion in the systematic review. From screening and early full text assessment it appears there are conflicting results regarding the role of alcohol consumption in NAFLD progression. Some studies report a protective effect and other studies suggest that any level of alcohol consumption is harmful in those with diagnosed NAFLD. The systematic review and conclusions will be completed and presented at the SAPC annual conference.

Consequences

With increasing levels of obesity and Type 2 Diabetes we are going to be diagnosing an increasing number of individuals with NAFLD. These people will be drinking alcohol in varying amounts and looking for advice from primary care practitioners. This systematic review will allow GPs to give evidence based advice to this increasing population.