What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?

In patients with AUD and co-occurring liver disease, I think the hepatotoxicity concerns around naltrexone have historically been overstated relative to both the actual evidence and the hepatic risk of ongoing alcohol exposure itself. The original 1980s data that triggered the FDA hepatotoxicity war...

It is widely accepted that if liver enzymes are 3x above the normal limit, it is not advised to start naltrexone. Between 1-3x the upper limit, one has to do a pro and con analysis of whether the benefits of alcohol cessation would outweigh potential liver toxicity from naltrexone. Further, naltrexo...