Table 1.

COVID-19 and alcohol-associated liver disease.

Alcohol Consumption and Alcohol Use Disorder
Epidemiology	-AUD prevalence was rising pre-pandemic [1] -Alcohol sales increased in the first year of the pandemic [7] -Alcohol-related hospitalizations and alcohol-related mortality increased post-pandemic [2,10,11]
Mechanisms	-Mass traumatic events associated with short-term increases in alcohol consumption [5] -Financial insecurity and unemployment associated with increased substance use disorders [6] -Psychological distress and isolation [4,12,13]
Impaction on Substance Use Disorder Treatment	-Group SUD treatment curtailed [14,15] -Residential treatment settings impacted by COVID-19 [15,16]
Alcohol-Associated Liver Disease Epidemiology
Pre-Pandemic	-ALD prevalence increased prior to the pandemic [17] -Hospitalizations for AC and AH were rising [18,19] -ALD became the leading indication for liver transplantation [20,21]
Post-pandemic	-AH admissions increased more than 50% [24,25] -ALD mortality accelerated during the covid 19 pandemic, increasing more than 20% in males and females [26] -Females and younger adults experienced highest relative increases in ALD [26]
Impact on Alcohol-Associated Liver Disease Outcomes
Rising Alcohol Consumption	-Alcohol use in cirrhosis associated with increased mortality, infection, and gastrointestinal bleeding [30,31] -Higher prevalence of ALD in ACLF hospital admissions [32] -Alcohol consumption may have a detrimental impact on the immune system [33,34]
COVID-related outcomes	-Patients with ALD have increased risk of severe illness and death from COVID-19 [36], [37], [38] -Patients with cirrhosis had a 30% case fatality rate [36,37] -COVID-19 can provoke ACLF [36] -ALD has the highest case-fatality rate of all etiologies of liver disease [38,39]
Impact on ALD Treatment and Liver Transplantation
ALD Treatment	-Early in the pandemic, cirrhosis and ALD-related hospitalizations declined likely reflecting delays in care [40] -Access to outpatient hepatology treatments and early alcohol treatment may have been impacted by COVID-19
Liver Transplantation	-Transplant candidates have increased risk of severe COVID-19 and death [47] -Transplants for severe AH increased by more than 50% during the COVID era and median MELD-Na at transplant rose [43,44]
Post-Transplant Care	-Concerns regarding immunosuppressed status, however mortality has been similar across LT-recipients and non-LT patients when accounting for other confounders [52]
Demographic Trends and Increasing Inequities
Pre-pandemic	-AUD and ALD prevalence highest in American Indian/Alaska Native Populations [1] -Racial and ethnic minority groups have worse AUD outcomes compared to White individuals [54] -Among patients hospitalized with cirrhosis, Black patients have the highest mortality [55]
Post-Pandemic	-Black and Hispanic/Latinx patients with CLD were disproportionately impacted by COVID-19 [60] -Highest relative increase in alcohol use in women and Black individuals [62] -Highest relative increase in AH admissions in women and Black patients [61] -Highest relative increase in ALD mortality in women and young adults [26]
*These disparities likely reflect inequitable access to treatment, social and economic exclusion, and other downstream sequelae of structural racism
Improving AUD and ALD Care During the COVID-19 Pandemic
Telemedicine	-Effective for providing specialty hepatology care [68] -Effective in reducing alcohol use [69,70] -Virtual and web-based programs during the pandemic were effective at treating AUD in ALD patients [71,72] -May neglect at-risk populations without stable housing or internet options [73]
Prevention and Treatment of COVID-19	-Vaccination should be emphasized for those with chronic liver disease -Medications for the treatment of COVID-19 need to be understood in the context of liver dysfunction
Response to Rising AUD and ALD
Prevention	-Improve public health messaging [77] -Higher taxation on alcohol has been associated with reduce alcohol consumption and lower ALD [84], [85], [86], [87]
Screening	-Sensitivity in primary care screening is < 50% and evidence-based tools are underused [78], [79], [80] -AUDIT-C or SASQ as evidence-based screening tools [81,82]
Treatment	-AUD treatment reduces hepatic decompensations and all-cause mortality in patients with cirrhosis [90] -Patients with ALD are often undertreated for their AUD [92] -Integrated care and team-based approaches should be used [94] -Profound shortage of addiction providers [97,98] -Brief alcohol interventions in primary care [99] -Collaborative care models for AUD in primary care [101]

ACLF; Acute-on-chronic liver failure. AH; Alcohol-associated hepatitis; ALD; Alcohol-associated liver disease. AUD; Alcohol use disorder. AUDIT-C; Alcohol use disorders identification test – consumption. CLD; Chronic liver disease. SASQ; Single alcohol screening question. SUD; Substance use disorder.