S1661 Pharmacologic Therapy for Alcohol Use Disorder is Under-Utilized in Alcohol-Associated Liver Disease Among Commercially Insured US Adults

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Introduction: Alcohol use disorder (AUD) is present in over half of patients with alcohol-associated liver disease (ALD). Treatment of AUD in ALD reduces morbidity and mortality—pharmacotherapy is an important modality for treating addiction and preventing progression of liver disease. We aimed to characterize pharmacologic treatment patterns and factors associated with pharmacologic therapy among AUD patients with and without liver disease including acute alcoholic hepatitis (AAH). Methods: Adult patients with AUD were identified from 2006-2021 using IQVIA PharMetrics Plus for Academics, a nationally representative database of commercially insured Americans. The primary outcome was receipt of AUD pharmacologic therapy any time after index AUD diagnosis. We used multivariable logistic regression to identify factors associated with receipt of AUD pharmacotherapy. Results: We identified a total of 28,625 patients with AUD: 26,985 without ALD, 1,201 with ALD, and 439 with AAH (Table); pharmacologic therapy was prescribed in 3,924 (14.5%) of patients without ALD, 28 (2.3%) with ALD, and 43 (9.8%) with AAH. One-time prescriptions were seen in 1,113 (28.4%) of the non-ALD, 3 (10.7%) of the ALD, and 8 (18.6%) of the AAH patients. The median time to prescription was 302 (interquartile range [IQR] 45-876) days with no significant difference based on presence of liver disease (Table, P=0.51). Gabapentin was the most commonly prescribed medication (9.4%) followed by oral naltrexone (2.6%) and topiramate (2.1%). In a multivariable logistic regression model, age ≥50 years (adjust odds ratio [aOR] 1.33, 95% confidence interval [CI] 1.23, 1.43), female sex (aOR 1.31, 95% CI 1.22, 1.41), non-liver Charlson Comorbdity Index ≥3 (aOR 2.21, 95% CI 1.80, 2.71), and psychiatric comorbidity (aOR 2.76, 95% CI [2.56, 2.98]) were associated with receipt of pharmacotherapy. Presence of hepatic decompensation (ascites, hepatic encephalopathy, or bleeding varices) (aOR 0.08 95% CI 0.03, 0.17) and non-AAH ALD (aOR 0.24, 95% CI 0.16, 0.35) were associated with lower odds of receiving pharmacotherapy. Conclusion: In a large nationally representative cohort of commercially insured patients, AUD pharmacotherapy was underutilized in at risk populations, especially patients with ALD, among whom just 1 in 50 received AUD therapy. Providers caring for patients with ALD should consider this underutilized therapy, or refer for psychiatric consultation when appropriate (see Table 1). Table 1. - Sociodemographic and clinical characteristics of patients with alcohol use disorder stratified by no ALD, non-AAH ALD, or AAH (N=28,625) Variable AUD Population TotalN=28,625 No ALDN=26,985 Non-AAH ALDN=1,201 AAHN=439 MedicationN=3,995 No MedicationN=24,630 P-value MedicationN=3,924 No MedicationN=23,061 P-value MedicationN=28 No MedicationN=1,173 P-value MedicationN=43 No MedicationN=396 P-value Age at AUD Diagnosis (Years; Median/IQR) 45 (33-53) 42 (27-52) < 0.001 45 (33-53) 40 (26-51) < 0.001 51.5 (42.5-57) 35 (48-59) 0.12 48 (39.5-53) 49 (40.75-55) 0.62 Male (%) 2,229 (56%) 16,243 (66%) < 0.001 2,182 (56%) 15,184 (66%) < 0.001 18 (64%) 813 (69%) 0.54 29 (67%) 246 (62%) 0.62 US Region Northeast 814 (20%) 6,195 (25%) < 0.001 803 (20%) 5,896 (26%) < 0.001 6 (21%) 223 (19%) 0.92 5 (12%) 76 (19%) 0.03 Midwest 1,183 (30%) 7,751 (31%) 1,162 (30%) 7,334 (32%) 8 (29%) 229 (25%) 13 (30%) 118 (30%) South 851 (21%) 4,519 (18%) 829 (21%) 4,173 (18%) 5 (18%) 265 (23%) 17 (40%) 81 (20%) West 1,147 (29%) 6,165 (25%) 1,130 (29%) 5,658 (25%) 9 (32%) 386 (33%) 8 (19%) 121 (31%) Year of AUD Diagnosis 2006-2009 765 (19%) 8,364 (34%) < 0.001 750 (19%) 7,905 (34%) < 0.001 3 (11%) 344 (29%) < 0.001 12 (28%) 115 (29%) 0.77 2010-2013 1,141 (29%) 7,643 (31%) 1,127 (29%) 7,161 (31%) 4 (14%) 378 (32%) 10 (23%) 104 (26%) 2014-2017 1,523 (38%) 6,378 (26%) 1,498 (38%) 5,874 (55%) 12 (43%) 379 (32%) 13 (30%) 125 (32%) 2018-2021 566 (14%) 2,245 (9%) 549 (14%) 2,121 (9%) 9 (32%) 72 (6%) 8 (19%) 52 (13%) Primary Insurance Type HMO 1,470 (37%) 7,432 (30%) < 0.001 1,445 (37%) 6,749 (29%) < 0.001 13 (46%) 550 (47%) >0.99 12 (28%) 133 (34%) 0.78 PPO 2,061 (52%) 13,486 (55%) 2,022 (52%) 12,752 (55%) 13 (46%) 514 (44%) 26 (60%) 220 (56%) Othera 464 (12%) 3,712 (15%) 457 (12%) 3,560 (15%) 2 (7%) 109 (9%) 5 (12%) 43 (11%) Primary Enrollment Type Commercial 2,843 (71%) 19,591 (80%) < 0.001 2,786 (71%) 18,603 (81%) < 0.001 20 (71%) 696 (59%) 0.35 37 (86%) 292 (74%) 0.17 Medicareb 249 (6%) 412 (2%) 246 (6%) 323 (1%) 3 (11%) 78 (7%) 1 (2%) 11 (3%) Otherc 903 (23%) 4,627 (19%) 892 (23%) 4,135 (18%) 6 (21%) 399 (34%) 5 (12%) 93 (23%) Modified CCI* 0-3 3,806 (95%) 24,244 (98%) < 0.001 3,738 (95%) 22,713 (98%) < 0.001 25 (89%) 1,143 (97%) 0.04 43 (100%) 388 (98%) >0.99 4-6 164 (4%) 327 (1%) 161 (4%) 294 (1%) 3 (11%) 26 (2%) 0 (0%) 7 (2%) ≥7 25 (1%) 59 (0%) 25 (1%) 54 (0%) 0 (0%) 4 (0%) 0 (0%) 1 (0%) CKD 82 (2%) 258 (1%) < 0.001 79 (2%) 178 (1%) < 0.001 3 (11%) 52 (4%) 0.13 0 (0%) 28 (7%) 0.10 ESRD 8 (0%) 25 (0%) 0.15 7 (0%) 16 (0%) 0.06 1 (4%) 3 (0%) 0.09 0 (0%) 6 (2%) >0.99 Diabetes 492 (12%) 1,830 (7%) < 0.001 484 (12%) 1,599 (7%) < 0.001 5 (18%) 185 (15%) 0.79 3 (7%) 46 (10%) 0.45 Neuropathy 331 (8%) 488 (2%) < 0.001 321 (8%) 400 (2%) < 0.001 5 (18%) 69 (6%) 0.03 5 (12%) 19 (4%) 0.07 Ascites 5 (0%) 578 (2%) < 0.001 1 (0%) 32 (0%) 0.10 3 (11%) 405 (35%) 0.008 1 (2%) 141 (36%) < 0.001 HE 0 (0%) 241 (1%) < 0.001 0 (0%) 5 (0%) 0.77 0 (0%) 174 (15%) 0.03 0 (0%) 62 (16%) 0.002 Variceal Bleeding 1 (0%) 167 (1%) < 0.001 0 (0%) 1 (0%) >0.99 1 (4%) 135 (12%) 0.36 0 (0%) 31 (8%) 0.06 HCC 1 (0%) 51 (0%) 0.02 0 (0%) 3 (0%) >0.99 1 (4%) 45 (4%) >0.99 0 (0%) 3 (1%) >0.99 Liver Transplant 0 (0%) 9 (0%) 0.47 0 (0%) 0 (0%) -- 0 (0%) 8 (1%) >0.99 0 (0%) 1 (0%) >0.99 Non-SUD Psychiatric Diagnosis 2,807 (70%) 10,321 (42%) < 0.001 2,754 (70%) 9,861 (43%) < 0.001 21 (75%) 302 (26%) < 0.001 32 (74%) 158 (40%) < 0.001 Non-Alcohol SUD Diagnosis 2,010 (50%) 8,217 (33%) < 0.001 1,978 (50%) 7,806 (34%) < 0.001 14 (50%) 290 (25%) 0.007 18 (42%) 121 (31%) 0.17 Time to Prescription (Days; Median/IQR) 302 (45-876) -- -- 301 (45-879) -- -- 334.5 (36.25-441.5) -- -- 367 (66.5-852.5) -- -- AUD, alcohol use disorder; ALD, alcohol-associated liver disease; AAH, acute alcoholic hepatitis; HMO, health maintenance organization; PPO, preferred provider organization; CCI, Charlson Comorbidity Index; CKD, chronic kidney disease; ESRD, end-stage renal disease; HE, hepatic encephalopathy; HCC, hepatocellular carcinoma; SUD, substance use disorder.a"Other" includes indemnity/traditional, point of service, consumer directed health care, or health savings accounts (HSA).bAdvantage or supplemental plan.c"Other" includes State Children's Health Insurance Plan (SCHIP), Medicaid, or self-insured * Excluding liver disease or severe liver disease from CCI calculation.

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