Background:
Alcohol Associated Hepatitis (AAH) is a severe form of alcohol-associated liver disease with limited therapeutic options and poor prognosis. AAH management, availability of early liver transplantation (LT), and practices regarding treating alcohol use disorder (AUD) vary between providers and centers. Our aim was to investigate AAH management practices internationally.

Methods:
This is an international survey study conducted between January and July 2023. A survey with 37-questions pertaining to management of AAH and AUD was developed and translated into Spanish, Portuguese, Chinese, Arabic, Italian, and German. The survey was sent out to 700 hepatologists, gastroenterologists, advanced-practice providers, and fellows.

Results:
Of the 700 surveys sent, 416 were partially completed and 344 were fully completed, with a completed response rate of 49%. Practice patterns varied by region and practice setting (transplant hospital vs. non-transplant) hospital. Greater than 75% of respondents from the United States (US), Canada, Central America and Mexico, South America, and Europe routinely use corticosteroids to treat AAH. Other than steroids, NAC was used by over 50% of respondents in the US, Canada, Asia, Europe, and the Middle East. Pentoxifylline was used by 52% of respondents from Central America and Mexico, 39% in Africa, and nearly 25% of those from Canada, South America, and the Middle East. Granulocyte stimulating factor was used by 25% of respondents from Asia. Access/referral for early LT ranged from 7% in Africa to 100% of Canada, with selection criteria varying considerably by region. Participation in the psychosocial assessment varied dramatically by region, with hepatologists having a central role in the US, Canada, Europe, and the Middle East. Nearly 90% of respondents from the US and Canada reported that social workers participated in the assessment. Prescriptions for AUD pharmacotherapy on discharge ranged from 67% in Canada to 0% in the Middle East. Choice of pharmacotherapy varied by region, with naltrexone or acamprosate favored in the US, baclofen in Europe and South America, and naltrexone favored in Asia, Canada, and the Middle East. Of prescribers who had access to early LT for AAH, only 20% of respondents did not recommend therapy on discharge, compared to 41% who did not have access to early LT, and 55% of those who did not know whether their patients had access.

Discussion:
This represents the first international survey on the management of AAH and demonstrates that management of AAH and AUD varies by region and by practice setting. This variability is likely due in part to availability of early LT but may also be secondary to practice culture, availability of services, education regarding treatment of AAH and AUD, and the limited availability of effective treatment options.

Figure 1 : Percent of prescribers who routinely treat AAH with corticosteroids by region.

Figure 2: Percent of prescribers that have access to offer early transplantation either in their transplant center or a referral center in various areas of practice.

Joaquin Cabezas

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