Evidence-Based Reviews

‘I’m sober, Doctor, really’: Best biomarkers for underreported alcohol use

Current Psychiatry. 2008 September;7(9):15-16,19-22,27

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Similarly, combinations of biochemical markers—especially CDT and GGT—have improved detection of alcohol use and subsequent risk of withdrawal.²⁶Table 4 provides a summary of studies that evaluated using combinations of biochemical markers.^4,5,27-31

Table 4

Combining biomarker tests: An effective approach

Combination	Study	Sensitivity*
GGT + MCV	Morgan et al⁴	95%
GGT + CDT	Hietala et al⁵	90%
	Mundle et al²⁹	90%
	Bell et al³⁰	90%
	Sillanaukee et al³¹	95%
GGT + AST:ALT >2:1	Gluud et al²⁷	92%
GGT + AST:ALT >2:1	Morgan et al⁴	100%
MCV + AST:ALT >2:1	Kawachi et al²⁸	97%
MCV + AST:ALT >2:1	Morgan et al⁴	95%
GGT + MCV + AST:ALT >2:1	Morgan et al⁴	100%
GGT + MCV + CDT	Sillanaukee et al³¹	70%
* Sensitivity for detecting excessive alcohol consumption
AST: aspartate aminotransferase; ALT: alanine aminotransferase; CDT: carbohydrate deficient transferrin; GGT: gamma-glutamyl transferase; MCV: mean corpuscular volume

Consider patients’ comorbidities

Patients at risk for underreporting alcohol use include those with unemployment histories, previous alcohol treatment, and higher scores on the Alcohol Dependence Scale (18.5, SD=8.1).² Interpret biochemical testing results in the context of a patient’s overall clinical picture.

Clinical Point

A simultaneous 30% increase in CDT and GGT suggests relapse to alcohol use after abstinence

The following 2 case patients denied or underreported recent alcohol use but we determined they were at high risk for an alcohol disorder because of their medical and/or psychiatric histories. Analysis of biochemical markers helped assess the risk of alcohol withdrawal.

CASE 2: Altered mental status

Family members bring Mr. N, age 44, to the hospital because of his odd behavior. He presents with paranoid delusions and an inappropriate elated mood. His medical history includes acquired immune deficiency syndrome (AIDS). After cerebrospinal fluid analysis, computed tomography of the head, electroencephalogram, and metabolic workup are within normal limits, the patient is diagnosed with human immunodeficiency virus (HIV) mania and is admitted.

On admission, Mr. N denies alcohol use. A blood alcohol/urine toxicity screen is negative. One day after admission, Mr. M develops elevated blood pressure and tachycardia and reports headache and nausea.

Challenge. Gathering a valid history of Mr. N’s alcohol use is difficult because of his acutely altered mental status and manic-like state. We use laboratory data to assess his risk of alcohol withdrawal. His liver function tests include an AST of 33 U/L, ALT of 30 U/L, and an alkaline phosphatase of 94 U/L. MCV is normal at 90 fL. Interestingly, the GGT level is elevated almost 4 times normal at 164 U/L.

Clinical Point

Risk factors for underreporting alcohol use include a history of unemployment and previous alcohol treatment

Discussion. Although Mr. N denied alcohol use and presented with a negative BAL, laboratory data support alcohol dependence. His GGT was elevated well beyond normal limits, without evidence of hepatobiliary disease. GGT has a sensitivity as high as 85%³² and limited specificity for alcohol abuse. Because of his high probability of recent alcohol consumption, we place Mr. N on AWP.

We postulate that our patient’s autonomic instability, headache, and nausea are related to alcohol withdrawal. We are aware that delirium occurs frequently in patients with HIV infection, and although Mr. N’s medical workup is negative, HIV infection can produce an acute encephalopathy that could resemble our patient’s clinical picture.³³

Mr. N’s autonomic instability, headache, and nausea abated after treatment for alcohol withdrawal.

CASE 3: Suicide attempt?

Mr. S, age 28, presents to the trauma service with a self-inflicted gunshot wound to the face. He reports feeling depressed for the last year but denies a history of psychotic symptoms or heroin withdrawal symptoms. He also denies recent or past alcohol abuse and does not have a history of biliary tract disease or megaloblastic anemia. His mother tells us Mr. S has had a history of depression since childhood.

Challenge. Based on Mr. S’ apparent suicide attempt and history, we feel he is at high risk for alcohol abuse. We use laboratory markers to assess the likelihood of alcohol consumption and possibly decrease his risk of alcohol withdrawal.

Clinical Point

Interpret biomarker results in the context of the patient’s overall clinical picture

Discussion. Mr. S’ lab data show an MCV of 91 fL, AST of 95 U/L, alanine ALT of 156 U/L, and alkaline phosphatase of 160 U/L. GGT was elevated at 122 U/L.

Although Mr. S’ MCV is within the normal range, his GGT is elevated, and the combination of an elevated GGT and MCV has a 95% sensitivity for the diagnosis of alcohol abuse. We place Mr. S on alcohol withdrawal precautions and discuss with him the potential life-threatening complications of alcohol withdrawal. Confronted with this information and the possible implication of his elevated LFTs, the patient admits his alcohol history—which consists of drinking 12 beers/day for at least the past 2 years. He admits this despite exhibiting no signs or symptoms of alcohol withdrawal.