Much progress has been made in the understanding of the pathogenesis of
alcoholic liver disease, resulting in an improvement in treatment.
Nutritional deficiencies should be corrected when present but, because of the alcohol-induced disease process, some of the nutritional requirements change. For instance,
methionine, one of the
essential amino acids for humans, must be activated to
S-adenosylmethionine (SAMe), but, in severe
liver disease, the activity of the corresponding
enzyme is depressed. Therefore, the resulting deficiencies and associated pathology can be attenuated by the administration of SAMe, but not by
methionine. Similarly,
phosphatidylethanolamine methyltransferase (PEMT) activity, which is important for hepatic
phosphatidylcholine (PC) synthesis, is also depressed in
alcoholic liver disease, therefore calling for the administration of the products of the reaction. Inasmuch as
free radical generation by the
ethanol-induced
CYP2E1 plays a key role in the oxidative stress, inhibitors of this
enzyme have great promise and PPC, which is presently being evaluated clinically, is particularly interesting because of its innocuity. In view of the striking negative interaction between alcoholic liver injury and
hepatitis C, an
antiviral agent is eagerly awaited that, unlike
Interferon, is not contraindicated in the alcoholic. Antiinflamatory agents may also be useful. In addition to
steroids, down-regulators of
cytokines and
endotoxin are being considered. Finally, anticraving agents such as
naltrexone or
acamprosate should be incorporated into any contemplated therapeutic cocktail.