COVID-19 and Alcohol-associated Liver Disease

COVID-19 and Alcohol-associated Liver DiseaseModerated by: Ashwani K. Singal, MD, MS, FACG, FAASLD& Pranoti Mandrekar, PhD, FAASLD

© 2020 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES WWW.AASLD.ORG

Webinar ModeratorsAshwani K. Singal, MD, MS, FACG, FAASLD• Associate Professor of

Medicine, University of South Dakota

• Chair – AASLD Alcohol-associated Liver Disease SIG

Pranoti Mandrekar, PhD, FAASLD• Professor, University of

Massachusetts Medical School

• Chair-Elect – AASLD Alcohol-associated Liver Disease SIG

14© 2020 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES WWW.AASLD.ORG

Webinar Agenda


Talks Speakers

Webinar and Presenter Introductions Drs. Pranoti Mandrekar & Dr. Ashwani Singal

"Alcohol Use During COVID-19: Impact Unknown” Dr. Brenda Curtis

“How is COVID-19 Affecting Alcohol-Associated Liver Disease?” Dr. Andrew Moon

Panel Discussion / Q&A All

Webinar Q&A• Submit your questions anytime during the webinar in the Q&A

box at the top or bottom of your screen.

• Questions will be answered at the end of the presentations.


Webinar PresenterBrenda Curtis, PhD MsPH

• Tenure Track Investigator• Technology and Translational

Research Unit, Chief • Translational Addiction Medicine

Branch, NIDA-IRP


Webinar PresenterAndrew Moon, MD, MPH• Advanced/Transplant Hepatology

Fellow, University of North Carolina


Webinar PanelistElizabeth C. Verna, MD, MSc• Director of Clinical Research,

Columbia University Transplant Initiative and the Transplant Clinical Research Center

• Director of Hepatology Research, Columbia University Division of Digestive and Liver Disease

Oren K. Fix, MD, MSc, FAASLD • Medical Director, Liver

Transplant Program, Swedish Medical Center, Seattle, WA

• Clinical Associate Professor, Washington State University Elson S. Floyd College of Medicine


Alcohol Use During COVID-19: Impact UnknownBrenda Curtis, PhD, MsPHNIDA/IRP Technology and Translational Research UnitTranslational Addiction Medicine Branch


Covid 19, Alcohol Consumption & Potential Impacts

• Alcohol Consumption & the Immune System

Susceptibility & Severity

• Stress, Anxiety, & Well-being

Consumption & AUD symptoms

• Social Isolation & Physical Distancing

Consumption & AUD symptoms

• Alcohol-Associated Liver DiseaseHealthcare access & treatment

Covid 19 & Alcohol Consumption• Early epidemiological and marketing data

indicate a spike in use of alcohol and other drugs by the general population.

• Week ending March 21, sales of distilled liquor were 75% greater than during the same week in 2019; beer sales, 66% greater

• Compared with this time a year ago, during the seven-week COVID-impacted period ended April 25,

• brick-and-mortar alcohol dollar sales up 26%

• online sales of alcohol have skyrocketed 477%

Digital Phenotyping, AUD research & COVID-19

24© 2020 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES WWW.AASLD.ORG Unpublished. Curtis, Epstein, Leggio, 2020

Specific AimsExamine

Examine effects of the Covid-19 pandemic on drug use, drug-related behaviors, consequences of drug use, in people with and without AUD/SUDs at the start of the study

Investigate

Investigate bidirectional effects between the Covid-19 pandemic and access/adherence to treatment, in people who have or develop AUD/SUDs

Improve

Improve our methodology for the detection of daily-life behavioral markers of:

• movement patterns, weight/diet• social interactions, support, &

distancing• substance use• resilience and wellbeing• psychological problems

Unpublished. Curtis, Epstein, Leggio, 2020

Study Design

BaselineN=2500

Social Media

PHQ-9

Drug Use

GAD-7

COVID

….

30 Days DAY 60

Social Media

PHQ-9

Drug Use

GAD-7

COVID

….

Day 90

Social Media

PHQ-9

Drug Use

GAD-7

COVID…

.

Day 120

Social Media

PHQ-9

Drug Use

GAD-7

COVID

….

Smartphone Sensor StudyN=300

EMA


Smartphone Sensor Study: Digital Phenotyping

Sensor Data Source Behavior

Physical Movement Social Interactions

Daily Activities

Accelerometer

Bluetooth

GPS

Light sensor

Wi-Fi scans

Phone use logs (call/SMS)

App use logs

Social Media Language*

● N = 568, Mean Age = 35.84, SD = 13.07● 74% White● 62% Bachelor’s degree or higher● 45% under $50k income● Substance use history:

○ 60% Cannabis○ 78% Alcohol○ 30% Opiates○ 12% Cocaine

Preliminary Results - Demographics


Preliminary Results Experiences During COVID-19

● 4% diagnosed with COVID-19● Concern for themselves (82%) or loved ones (89%) getting

COVID-19● More anxiety (77%) and depression (53%)● Personal financial loss (77%)● Increase in alcohol use (28%)


Language more frequently used in 2020

Changes in language estimated psychological distress

Language changes in 2020 (vs 2019)


Physical DistancingData from the UK: (telephone survey 2 months after lockdown, pre-existing AUD patients)

• 20% of individuals increasing or decreasing their normal alcohol consumption

• Decrease probably associated with decrease financial ability and decreased availability of on-site alcohol areas

References


Retail Analytics: Nielsen. https://twitter.com/nielsen/status/1248366074317418498. Accessed Dec 2, 2020.

Rebalancing the ‘Covid-19 Effect’ on Alcohol Sales: Nielsen. https://www.nielsen.com/us/en/insights/article/2020/rebalancing-the-covid-19-effect-on-alcohol-sales/#:~:text=A%20Nielsen%20investigation%20of%20the,of%20closed%20bars%20and%20restaurants. Accessed Dec 2, 2020.

Da, B. L., Im, G. Y., & Schiano, T. D. (2020). COVID-19 hangover: a rising tide of alcohol use disorder and alcohol-associated liver disease. Hepatology, 72(3)), 1102-8.

Micallef JV. How The COVID-19 Pandemic is Upending the Alcoholic Beverage Industry. Forbes. April 4, 2020.

Cotti C, Dunn RA, Tefft N. The Dow is Killing Me: Risky Health Behaviors and the Stock Market. Health Economics 2015;24:803-821.

Black H, Gill J, Chick J. The price of a drink: levels of consumption and price paid per unit of alcohol by Edinburgh's ill drinkers with a comparison to wider alcohol sales in Scotland. Addiction (Abingdon, England) 2011;106:729-736.

https://www.nielsen.com/us/en/insights/article/2020/rebalancing-the-covid-19-effect-on-alcohol-sales/#:%7E:text=A%20Nielsen%20investigation%20of%20the,of%20closed%20bars%20and%20restaurants

References


Kushner, T., & Cafardi, J. (2020). Chronic Liver Disease and COVID-19: Alcohol Use Disorder/Alcohol-Associated Liver Disease, Nonalcoholic Fatty Liver Disease/Nonalcoholic Steatohepatitis, Autoimmune Liver Disease, and Compensated Cirrhosis. Clinical Liver Disease, 15(5), 195.

Kim, J. U., Majid, A., Judge, R., Crook, P., Nathwani, R., Selvapatt, N., ... & Lewis, H. (2020). Effect of COVID-19 lockdown on alcohol consumption in patients with pre-existing alcohol use disorder. The Lancet Gastroenterology & Hepatology, 5(10), 886-887.

Alcohol Change UK. Drinking during lockdown: headline findings. https://alcoholchange.org.uk/blog/2020/covid19-drinking-during-lockdown-headline-findings. Accessed Dec 1, 2020

https://alcoholchange.org.uk/blog/2020/covid19-drinking-during-lockdown-headline-findings

How is COVID-19 Affecting Alcohol-Associated Liver Disease?Andrew M. Moon, MD, MPHAdvanced/Transplant Hepatology FellowUniversity of North Carolina© 2020 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES WWW.AASLD.ORG

DisclosuresNo potential conflicts of interest to disclose.

My research was supported in part by NIH grant T32 DK007634.


Pre-COVID Burden of ALD


Rising Prevalence and Costs of ALD


Mellinger et al. Hepatology 2018. Hirode et al. JAMA Netw Open 2020.Barritt et al. Dig Dis Sci 2020.

ALD Most Common LT Indication


Lee et al. JAMA Intern Med 2019.

ALD Deaths on the Rise


Moon et al. Am J Gastroenterol 2020.

AAPC (1999-2017)

Women, 25-34 6.07 (2.95-9.28)

Women, 65-74 1.81 (0.92-2.71)

Men, 25-34 4.95(3.21-6.73)

Men, 65-74 1.15(0.31-2.00)

COVID-19 Outcomes in ALD


COVID-19 in ALD

© 2020 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES WWW.AASLD.ORG41

42Marjot et al, J Hepatol 2020.

COVID-19 in ALD

Effects of Excess Alcohol Use on ALD


Effect of Excess Alcohol Use on ALD

44

Unsafe Alcohol Use

d

d

Binge Drinking

2h

2h

Crabb et al. Hepatology 2019.

45

Effect of Excess Alcohol Use on ALD

Mellinger et al. Alcohol Clin Exp Res 2019.

Effect of Alcohol Use on Mortality in AH

46© 2020 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES WWW.AASLD.ORGLlouvet et al. Hepatology 2017.

Follow-up:3 mos x 1 year6 mos thereafter

Median Follow-up 42 months

70% mortality in steroid non-responders at 6 mos

Effect of Alcohol Use on Mortality in ALD


Verrill et al. Addiction 2009.

cum

ulat

ive

surv

ival

(%)

Effect of COVID-19 on ALD?


Cirrhosis Hospitalizations in COVID Era

49Mahmud et al, Gastroenterology 2020.

Post-COVID Increase in AH

50

© 2020 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES WWW.AASLD.ORG Moon et al. (unpublished data)

Stay at home order

Admissions % ChangeMay-Oct 19 377 -May-Oct 20 505 +34%

De-Listing from Liver Transplant List


Increased risk of relapse in listed

patients

Kim et al. Lancet Gastro & Hep 2020.

Delisting

Conclusions• Prior to COVID-19, alcohol-associated liver disease had a large

and growing burden• COVID-19 outcomes may be worse in ALD patients• Psychosocial strain and limited access to healthcare has likely

led to higher risk alcohol consumption patterns• Increased alcohol use has the potential to significantly increase

morbidity and mortality from ALD• Early data suggest that patients with ALD may be experiencing

increased complications and poor outcomes in COVID-19 era


Thank you and stay safe!

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@AndrewMMoon

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Panel DiscussionPlease submit your questions to the Q&A Chat now.


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COVID-19 and Alcohol-associated Liver Disease