EASL Clinical Practice Guidelines: Management of alcohol-related liver disease

Abstract

The harmful use of alcohol has been estimated to cause approximately 3.3 million deaths every year, corresponding to nearly 6% of all deaths globally. Therefore, the effective management and treatment of alcoholic liver disease is a pertinent public health issue. In the following Clinical Practice Guidelines, the latest data on the treatment and management of alcohol-related liver disease will be reviewed and up to date recommendations for clinical management will be provided. The harmful use of alcohol has been estimated to cause approximately 3.3 million deaths every year, corresponding to nearly 6% of all deaths globally. Therefore, the effective management and treatment of alcoholic liver disease is a pertinent public health issue. In the following Clinical Practice Guidelines, the latest data on the treatment and management of alcohol-related liver disease will be reviewed and up to date recommendations for clinical management will be provided. A panel of clinicians with an interest in liver disease and alcoholic liver disease (ALD), approved by the European Association for the Study of the Liver (EASL) Governing Board, wrote and discussed this Clinical Practice Guidelines (CPG) document between November 2016 and March 2017. The guidelines were independently peer reviewed, and all contributors to the CPG disclosed their conflicts of interest by means of a disclosure form provided by the EASL Office prior to work commencing. The EASL Ethics Committee reviewed the composition of the panel to eliminate the potential for real or perceived bias. The CPG panel conflict of interests are declared in this submission. These guidelines have been produced using evidence published before 1 October, 2017. Where possible, the level of evidence and recommendation are cited (Table 1). The evidence and recommendations in these guidelines have been graded using methods adapted from the grading of recommendations assessment development and evaluation (GRADE system). The strength of recommendations thus reflects the quality of underlying evidence. The GRADE system offers two grades of recommendation: strong or weak (Table 1). The CPG thus consider the quality of evidence: the higher, the more likely a strong recommendation is warranted; the greater the variability in values and preferences, or the greater the uncertainty, the more likely a weaker recommendation is warranted. Where no clear evidence exists, guidance is based on the consensus of expert opinion in the literature and the writing committee. Recommendations must also be interpreted in a context specific manner.Table 1Level of Evidence and Grade of Recommendations (adapted from GRADE system).Level of evidence*Level was graded down if there is a poor quality, strong bias or inconsistency between studies. Level was graded up if there is a large effect size.Confidence in the evidenceLevel 1Data derived from meta-analyses or systematic reviews or from (multiple) randomized trials with high quality.Further research is unlikely to change our confidence in the estimate of benefit and risk.Level 2Data derived from a single RCT or multiple non-randomized studiesFurther research (if performed) is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate.Level 3Small studies, retrospective observational studies, registries.Any estimate of effect is uncertain.RecommendationsGradeWording associated with the grade of recommendationA (strong)Strong recommendation: factors influencing the strength of the recommendation include the quality of the evidence, presumed patients-important outcomes and cost“must”, “should”, or “EASL recommends”B (weak)Weaker recommendation: variability in preferences and values, or more uncertainty. Recommendation is made with less certainty, higher cost or resource consumption“can”, “may”, or “EASL suggests”* Level was graded down if there is a poor quality, strong bias or inconsistency between studies. Level was graded up if there is a large effect size. Open table in a new tab The term alcoholic is stigmatising and undermines patient dignity and self-esteem. For this reason, these guidelines will use the following terms (Box 1):Tabled 1 Open table in a new tab ∗However, at this point the term alcoholic hepatitis has become too standardised to change but may be reviewed in future guidelines. According to the World Health Organization’s (WHO) 2014 report on noncommunicable diseases, harmful use of alcohol causes approximately 3.3 million deaths every year, corresponding to 5.9% of all deaths. Furthermore, 139 million disability-adjusted life years, or 5.1% of the global burden of disease and injury, were attributable to alcohol consumption. The proportion of global deaths attributable to alcohol differs based on gender, with 7.6% of deaths among males and 4.0% of deaths among females attributable to alcohol.[1]WHO. GLOBAL STATUS REPORT on noncommunicable diseases 2014. WHO Library Cataloguing-in-Publication Data; 2014.Google Scholar Alcohol-related morbidity and mortality has a wide geographical variation, with the highest alcohol-attributable fractions reported in the WHO European Region.[1]WHO. GLOBAL STATUS REPORT on noncommunicable diseases 2014. WHO Library Cataloguing-in-Publication Data; 2014.Google Scholar Within each country there is an excellent correlation between the level of alcohol consumption and the prevalence of alcohol-related harm. In fact, although mean alcohol consumption in the World is 6.2 litres of pure alcohol per person per year, the consumption in Europe is 10.9 litres/year.[1]WHO. GLOBAL STATUS REPORT on noncommunicable diseases 2014. WHO Library Cataloguing-in-Publication Data; 2014.Google Scholar According to data from the OECD report 2017, alcohol consumption in the OECD countries, averaged nine litres of pure alcohol per person per year. This number results from a significant percentage of heavy drinkers: 30% of men and 12% of women binge-drink at least once per month.[2]OECD. Alcohol consumption among adults. In: Health at a Glance 2017.2017:72–73.Google Scholar Despite divergent trends at the national level, the WHO European Region is still the region with the highest adult per capita alcohol consumption. Between 1990 and 2014, there was a slight decrease in the overall level of consumption due to decreases in the richest countries in the central western European Union (EU) and Mediterranean parts of the Region, while drinking levels in central-eastern EU remained stable over the past 25 years, and increased in the eastern and the south-eastern parts of the WHO European Region.[3]Shield KDR, M.M., Rehm, J. Public health successes and missed opportunities Trends in alcohol consumption and attributable mortality in the WHO European Region, 1990–2014. In. WHO. Copenhagen, Denmark: WHO Regional Office for Europe; 2016.Google Scholar Alcohol consumption over the last 20 years in the UK and Finland has increased significantly, while other countries such as France, Spain and Portugal were able to reduce the number of liver-related deaths.[4]Sheron N. Alcohol and liver disease in Europe-Simple measures have the potential to prevent tens of thousands of premature deaths.J Hepatol. 2016; 64: 957-967Abstract Full Text Full Text PDF PubMed Google Scholar Alcohol has an impact on over 200 diseases and types of injuries. In most cases the impact is detrimental. The largest number of deaths attributable to alcohol consumption are from cardiovascular diseases, followed by injuries, gastrointestinal diseases (mainly liver cirrhosis) and cancers.[5]OECD. Tackling Harmful Alcohol Use: Economics and Public Health Policy. Paris 2015.Google Scholar However, the alcohol-attributable fraction is highest for liver diseases, especially cirrhosis, and foetal alcohol syndrome.[1]WHO. GLOBAL STATUS REPORT on noncommunicable diseases 2014. WHO Library Cataloguing-in-Publication Data; 2014.Google Scholar In the EU, based on the WHO mortality database, 41% of the liver deaths are attributed to alcohol, and 46% are of unknown aetiology. It is probable that a significant percentage of those classified as unknown are actually due to alcohol.[4]Sheron N. Alcohol and liver disease in Europe-Simple measures have the potential to prevent tens of thousands of premature deaths.J Hepatol. 2016; 64: 957-967Abstract Full Text Full Text PDF PubMed Google Scholar In fact, reliability of death certificate codification varies among countries, and in an undetermined proportion of deaths in which alcohol is the key factor the certifying doctor may choose not to explicitly mention alcohol on the death certificate.[6]Bell G. Cremona A. Alcohol and death certification: a survey of current practice and attitudes.Br Med J. 1987; 295: 95Crossref PubMed Google Scholar Although alcohol consumption is higher in rich countries, in those with lower economic wealth, the morbidity and mortality risks are higher per litre of pure alcohol consumed than in the higher income countries.[1]WHO. GLOBAL STATUS REPORT on noncommunicable diseases 2014. WHO Library Cataloguing-in-Publication Data; 2014.Google Scholar The economic contribution of the alcohol industry, in terms of employment and taxation, are often cited as reasons for not attempting to restrict alcohol consumption using pricing strategies or marketing restrictions. In the EU in 2003, it was calculated that harmful alcohol consumption resulted in estimated costs of €125 billion, equivalent to 1.3% of gross domestic product (GDP).[7]SANCO D. Alcohol-related harm in Europe: Key Data, Factsheet. In: SANCO D, ed. Belgium 2006.Google Scholar This exceeds by an order of magnitude the reported contribution (about €9 billion) of the alcohol industry to the EU economy.[8]Rabinovich L, Brutscher P-B, de Vries H, Tiessen J, Clift J, Reding A. The affordability of alcoholic beverages in the European Union Understanding the link between alcohol affordability, consumption and harms. Rand report 2009; http://ec.europa.eu/health/ph_determinants/life_style/alcohol/documents/alcohol_rand_en.pdf, 2018Google Scholar The quantification of alcohol consumption is not easy in clinical practice. Although the quantification in grams of alcohol per/day or week is more precise, it is time-consuming and frequently difficult to obtain, since patients are not able to recall the different types of drinks and their amount. Consequently, it may be advantageous to quantify by number of drinks. However, there has been large discrepancy in the definition of a “drink”, regarding the grams of alcohol, varying from 8 to 16 g. According to the Dietary guidelines for Americans, one standard drink of “pure” alcohol is defined as 14 g.[9]DHHS, DoA. 2015–2020 Dietary Guidelines for Americans. In: 8th ed. http://health.gov/dietaryguidelines/2015/guidelines/2015.Google Scholar We suggest standardising the measure to 10 g, to facilitate comparisons among studies, as has been used by the WHO.[10](WHO) WHO. Food based dietary guidelines. 2003.Google Scholar According to ICD-10, harmful drinking is considered when alcohol use is causing damage to health that may be either physical or mental: IC10-2016 online (http://apps.who.int/classifications/icd10/browse/2016/en#/F10.1) Heavy episodic drinking has been defined as consumption of more than 60 g of pure alcohol on one occasion.[11]Rehm J. Gmel Sr., G.E. Gmel G. Hasan O.S.M. Imtiaz S. Popova S. et al.The relationship between different dimensions of alcohol use and the burden of disease-an update.Addiction. 2017; 112: 968-1001Crossref PubMed Scopus (47) Google Scholar Binge drinking is the consumption within about two hours of four or more drinks for women and five or more drinks for men.[9]DHHS, DoA. 2015–2020 Dietary Guidelines for Americans. In: 8th ed. http://health.gov/dietaryguidelines/2015/guidelines/2015.Google Scholar An important aspect of public health policy concerning alcohol has been the attempt to establish a safe threshold for consumption. This pertains mostly to what extent moderate alcohol consumption is cardio-protective, illustrated by the so called ‘J’ shaped curve in the relationship between alcohol consumption and overall mortality.[12]Corrao G. Rubbiati L. Bagnardi V. Zambon A. Poikolainen K. Alcohol and coronary heart disease: a meta-analysis.Addiction. 2000; 95: 1505-1523Crossref PubMed Scopus (605) Google Scholar Although there is strong evidence that heavy alcohol intake associates with increased risk of cardiomyopathy, hypertension, atrial arrhythmias and haemorrhagic stroke, light–moderate drinkers seem to have a lower risk of coronary artery disease.[13]Klatsky A.L. Alcohol and cardiovascular diseases: where do we stand today?.J Intern Med. 2015; 278: 238-250Crossref PubMed Scopus (38) Google Scholar This positive effect of alcohol may offset some of the large array of negative health consequences of even moderate alcohol consumption. However, alcohol is a recognised carcinogen, and no threshold level of consumption exists for the risk of cancer. Alcohol consumption has been associated with an increased risk of several cancers, and in at least four of them, including breast cancer, the risk begins at doses as low as 10 g/1 unit/day.[14]Bagnardi V. Rota M. Botteri E. Tramacere I. Islami F. Fedirko V. et al.Alcohol consumption and site-specific cancer risk: a comprehensive dose-response meta-analysis.Br J Cancer. 2015; 112: 580-593Crossref PubMed Scopus (175) Google Scholar While alcohol is undoubtedly a risk factor for cirrhosis it is still unclear whether there is a continuous dose-response relationship or a threshold of consumption at which the risk emerges. In a meta-analysis from 2010 the close dose-response relationships between the average amount of alcohol consumed and the risk of liver cirrhosis were confirmed. The authors’ found evidence for threshold effects, with increased risks of mortality from liver cirrhosis among men and women drinking 12–24 g of ethanol per day.[15]Rehm J. Taylor B. Mohapatra S. Irving H. Baliunas D. Patra J. et al.Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis.Drug Alcohol Rev. 2010; 29: 437-445Crossref PubMed Scopus (202) Google Scholar Indeed, among women, a significant increase was also seen for those drinking up to 12 g/day. The evidence therefore suggests that if a threshold exists, it is very low, and may in fact be difficult to detect because of limitations in measuring consumption. However, for practical issues, it can be recommended that if alcohol is consumed, limit intake to no more than two drinks for females and three drinks for males (each containing 10 g of alcohol) per day, since this amount was not associated with a significant increase in risk of liver cirrhosis morbidity.10(WHO) WHO. Food based dietary guidelines. 2003.Google Scholar, 15Rehm J. Taylor B. Mohapatra S. Irving H. Baliunas D. Patra J. et al.Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis.Drug Alcohol Rev. 2010; 29: 437-445Crossref PubMed Scopus (202) Google Scholar One important issue is the impact of alcohol drinking patterns, with controversy regarding the risks of binge drinking. In that respect, Askgaard found that daily drinking was associated with the highest risk of liver cirrhosis,[16]Askgaard G. Gronbaek M. Kjaer M.S. Tjonneland A. Tolstrup J.S. Alcohol drinking pattern and risk of alcoholic liver cirrhosis: a prospective cohort study.J Hepatol. 2015; 62: 1061-1067Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar whereas Aberg et al. found that binge drinking was associated with an increased risk of liver disease independently of average alcohol intake and confounders.[17]Aberg F. Helenius-Hietala J. Puukka P. Jula A. Binge drinking and the risk of liver events: A population-based cohort study.Liver Int. 2017; PubMed Google Scholar Further clinical and experimental studies are required to define the role of ALD and the underlying mechanisms. Importantly, there is good clinical evidence that cessation of drinking at any point in the natural history of the disease reduces the risks of disease progression and occurrence of complications from cirrhosis.[18]Masson S. Emmerson I. Henderson E. Fletcher E.H. Burt A.D. Day C.P. et al.Clinical but not histological factors predict long-term prognosis in patients with histologically advanced non-decompensated alcoholic liver disease.Liver Int. 2014; 34: 235-242Crossref PubMed Scopus (12) Google Scholar Several alcohol-related policies have been shown to be effective and cost-effective. Reducing morbidity and mortality associated with ALD, depends on policies that reduce alcohol consumption in general. Effective interventions include:•Price based policiesoTaxationoMinimum unit pricing•Limitation of alcohol availability•Restriction of marketing and advertising Reducing the affordability of alcohol has been shown to have a significant effect on reducing ALD-related liver deaths.19Wagenaar A.C. Salois M.J. Komro K.A. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies.Addiction. 2009; 104: 179-190Crossref PubMed Scopus (449) Google Scholar, 20Wagenaar A.C. Tobler A.L. Komro K.A. Effects of alcohol tax and price policies on morbidity and mortality: a systematic review.Am J Public Health. 2010; 100: 2270-2278Crossref PubMed Scopus (200) Google Scholar Minimum unit pricing, setting a floor price for a unit of alcohol, has been shown to be very effective. In British Columbia, it reduced alcohol-related mortality by 32% one year after implementation.[21]Stockwell T. Zhao J. Martin G. Macdonald S. Vallance K. Treno A. et al.Minimum alcohol prices and outlet densities in British Columbia, Canada: estimated impacts on alcohol-attributable hospital admissions.Am J Public Health. 2013; 103: 2014-2020Crossref PubMed Scopus (45) Google Scholar This measure also has the advantage of being more effective for heavy consumers and for low-income groups. Other effective alcohol policies have been suggested by WHO, that are based on age-related vulnerability, including partial or total advertising bans, restrictions on access to alcohol through minimum ages at which it is legal to purchase alcohol, and laws aimed to prevent any alcohol consumption by young people when driving vehicles.[1]WHO. GLOBAL STATUS REPORT on noncommunicable diseases 2014. WHO Library Cataloguing-in-Publication Data; 2014.Google Scholar Children and young adults are particularly sensitive to alcohol marketing. A series of longitudinal experimental studies have proven that marketing impacts on the drinking behaviour of children.22Forum SGotEAaH. Does marketing communication impact on the volume and patterns of consumption of alcoholic beverages, especially by young people? – a review of longitudinal studies. In: DG SANCO EC, European Alcohol and Health Forum, ed2009.Google Scholar, 23Anderson P. de Bruijn A. Angus K. Gordon R. Hastings G. Impact of alcohol advertising and media exposure on adolescent alcohol use: a systematic review of longitudinal studies.Alcohol Alcohol. 2009; 44: 229-243Crossref PubMed Scopus (466) Google Scholar In fact, reducing advertising in media, mostly publicity targeting young people is important, since they have been shown to be particularly susceptible.[23]Anderson P. de Bruijn A. Angus K. Gordon R. Hastings G. Impact of alcohol advertising and media exposure on adolescent alcohol use: a systematic review of longitudinal studies.Alcohol Alcohol. 2009; 44: 229-243Crossref PubMed Scopus (466) Google Scholar A high proportion of patients admitted with decompensated ALD cirrhosis report having recent consultations in primary care or emergency units.[24]Verrill C. Smith S. Sheron N. Are the opportunities to prevent alcohol related liver deaths in the UK in primary or secondary care? A retrospective clinical review and prospective interview study.Subst Abuse Treat Prev Policy. 2006; 1: 16Crossref PubMed Scopus (11) Google Scholar Since the risk of developing liver disease in harmful drinkers decreases with abstinence or decreased consumption, early recognition and interventions with that goal should be implemented. Screening for harmful alcohol consumption should be done systematically in patients, by their general practitioner (GP), and in patients admitted to emergency facilities. In fact, the feasibility of screening followed by an intervention in an emergency department was recently demonstrated in the UK.[25]Westwood G. Meredith P. Atkins S. Greengross P. Schmidt P.E. Aspinall R.J. Universal screening for alcohol misuse in acute medical admissions is feasible and identifies patients at high risk of liver disease.J Hepatol. 2017; 67: 559-567Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar In addition, screening for ALD should be undertaken in patients with clinical signs suggestive of harmful alcohol consumption or liver cirrhosis, i.e. patients presenting with bilateral parotid gland hypertrophy, muscle wasting, malnutrition, Dupuytren’s contracture, gynecomastia or extensive spider naevi. Screening for ALD should be performed in high-risk populations, such as those in alcohol rehabilitations clinics, or harmful drinkers identified by their GP. Screening in the workplace would be extremely helpful, although difficult to implement.[26]Cook P.A. Morleo M. Billington D. Sanderson-Shortt K. Jones C. Gabbay M. et al.Evaluation of work-based screening for early signs of alcohol-related liver disease in hazardous and harmful drinkers: the PrevAIL study.BMC Public Health. 2015; 15: 532Crossref PubMed Scopus (1) Google Scholar The best way to do such screening is still debatable. The Southampton traffic-light test is an algorithm, based on hyaluronic acid (HA), procollagen-3 N-terminal peptide (PIIINP), and platelet count, that expresses the results as red, amber or green, corresponding respectively to high, intermediate or low risk, and was suggested as a simple screening test.[27]Sheron N. Moore M. O'Brien W. Harris S. Roderick P. Feasibility of detection and intervention for alcohol-related liver disease in the community: the Alcohol and Liver Disease Detection study (ALDDeS).Br J Gen Pract. 2013; 63: e698-e705Crossref PubMed Scopus (0) Google Scholar Another possibility is the use of transient elastography (TE) techniques that could be used in portable devices to increase availability for large groups. In fact, it was recently shown that TE has excellent diagnostic value for liver fibrosis in ALD.[28]Voican C.S. Louvet A. Trabut J.B. Njike-Nakseu M. Dharancy S. Sanchez A. et al.Transient elastography alone and in combination with FibroTest((R)) for the diagnosis of hepatic fibrosis in alcoholic liver disease.Liver Int. 2017; 37: 1697-1705Crossref PubMed Scopus (0) Google Scholar Whatever form of screening is used, it must be followed by an intervention with a multidisciplinary team. In fact, there is a need to create alcohol care teams to take care of these patients.[29]Hazeldine S. Hydes T. Sheron N. Alcoholic liver disease - the extent of the problem and what you can do about it.Clin Med. 2015; 15: 179-185Crossref PubMed Google Scholar •Priority to be given to further studies on screening in different populations, to diagnose patients prior to the development of end-stage liver diseaseRecommendations•Excess alcohol consumption should be addressed using pricing-based policies and regulation of availability. (Grade A1)•Advertising and marketing of alcohol either directly or indirectly should be banned. (Grade A2)•Primary care facilities for managing AUD need to be made widely available. (Grade A2)•Screening for harmful alcohol consumption should be done by GPs and in Emergency Departments. (Grade A2)•Screening for ALD should be done in high-risk populations, such as those in alcohol rehabilitations clinics, or the harmful drinkers identified by their GP. (Grade A2)•Patients identified through screening should undergo brief intervention and referral to a multidisciplinary team. (Grade A1) •Excess alcohol consumption should be addressed using pricing-based policies and regulation of availability. (Grade A1)•Advertising and marketing of alcohol either directly or indirectly should be banned. (Grade A2)•Primary care facilities for managing AUD need to be made widely available. (Grade A2)•Screening for harmful alcohol consumption should be done by GPs and in Emergency Departments. (Grade A2)•Screening for ALD should be done in high-risk populations, such as those in alcohol rehabilitations clinics, or the harmful drinkers identified by their GP. (Grade A2)•Patients identified through screening should undergo brief intervention and referral to a multidisciplinary team. (Grade A1) The publication of the DSM-V has been an important step forward to overcome the arbitrary differentiation between alcohol abuse and dependence, through the creation of the overarching concept of alcohol use disorder (AUD).[30]Association“ AP. American Psychiatric Association Substance use and addiction-related disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. American Psychiatric Association 2013:481–589.Google Scholar This new concept is not only useful because it unifies the disorder, but also because it introduces a partially dimensional perspective into what has been traditionally called alcoholism. The categorical distinction between who is and who is not an alcoholic is not clinically useful and may be damaging because of stigmatisation.[31]Rehm J. Anderson P. Manthey J. Shield K.D. Struzzo P. Wojnar M. et al.Alcohol use disorders in primary health care: what do we know and where do we go?.Alcohol Alcohol. 2016; 51: 422-427Crossref PubMed Scopus (22) Google Scholar Instead, the DSM-V defines AUD as a problematic pattern of alcohol use leading to clinically significant impairment or distress, with graded levels of severity depending on the number of diagnostic criteria met. As shown there are 11 diagnostic criteria and anyone meeting at least two of them during the last year qualifies for a diagnosis of AUD (Table 2). Severity is established based on the number of criteria met, ranging from mild (2–3 criteria), to moderate (4–5 criteria) and severe (6 or more criteria).Table 2DSM-V criteria for alcohol use disorder.Definition: A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:1. Alcohol is often taken in larger amounts or over a longer period than was intended.2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.4. Craving, or a strong desire or urge to use alcohol.5. Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home.6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.8. Recurrent alcohol use in situations in which it is physically hazardous.9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.10. Tolerance, as defined by either of the following:a.A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.b.A markedly diminished effect with continued use of the same amount of alcohol.11. Withdrawal, as manifested by either of the following:a.The characteristic withdrawal syndrome for alcoholb.Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.The presence of at least 2 of these criteria indicates an AUD. The severity of the AUD is defined as:Mild: The presence of 2 to 3 criteriaModerate: The presence of 4 to 5 criteriaSevere: The presence of 6 or more criteriaAUD, alcohol use disorder. Open table in a new tab AUD, alcohol use disorder. It is still unclear what option will be taken in ICD-11, but for the moment, the WHO continues to use the terms hazardous and harmful alcohol use and alcohol dependence [5]. Even though it is not officially accepted, the term ‘risky drinker’ is commonly used to define people who drink excessively and can benefit from brief interventions provided by health practitioners in medical settings. The drinking habits of patients with liver diseases need to be routinely assessed, using tools with proven reliability.[32]Zakhari S. Li T.K. Determinants of alcohol use and abuse: Impact of quantity and frequency patterns on liver disease.Hepatology. 2007; 46: 2032-2039Crossref PubMed Scopus (160) Google Scholar Quantity frequency questionnaires and diaries (Timeline Followback) can be used to calculate patients’ drinking habits. The former tools are usually preferred for their simplicity, but in the last few years a relevant number of Apps (e.g. Drinkaware) have been developed for this monitoring purpose,[33]Barrio P. Ortega L. Lopez H. Gual A. Self-management and shared decision-making in alcohol dependence via a mobile app: a pilot study.Int J Behav Med. 2017; 24: 722-727Crossref PubMed Scopus (1) Google Scholar making prospective measurement of drinking much easier for motivated patients. A good alternative to quantity frequency questionnaires is the use of screening instruments. There are many tools that have been validated and translated into many languages, but the AUDIT (Alcohol Use Disorders Inve