What laboratory data are most helpful in deciding whether to initiate corticosteroids for acute alcohol-associated hepatitis?

From the Guidelines

The most helpful data in deciding whether to start steroids for acute alcohol-associated hepatitis are Maddrey's discriminative function and MELD (Model for End-Stage Liver Disease). These scoring systems help clinicians assess the severity of alcohol-associated hepatitis and identify patients who would benefit from steroid therapy. Maddrey's discriminative function, calculated using prothrombin time and total bilirubin, indicates severe disease when the score is ≥32, suggesting a potential benefit from steroids 1. Similarly, a high MELD score (typically >20) indicates poor short-term prognosis and may support steroid initiation. These scoring systems are superior to other parameters like ultrasound findings, AST/ALT ratio, or isolated lab values because they incorporate multiple factors that collectively reflect disease severity and predict mortality risk.

Key Considerations

• The Maddrey score has been the most widely used score in both randomized trials and current practice, and a score of ≥32 indicates severe disease and potential benefit from steroids 1.
• The MELD score is more commonly used in English-speaking countries, and a high score (typically >20) indicates poor short-term prognosis and may support steroid initiation 1.
• Steroids (typically prednisolone 40mg daily for 28 days) are generally considered when these scores indicate severe disease, though clinicians should also evaluate for contraindications such as active infection, gastrointestinal bleeding, or renal failure before initiating treatment 1.
• The Lille score, calculated on the seventh day of treatment, can help identify patients who are not responding to treatment and may require alternative therapies 1.

Clinical Application

• Clinicians should use the Maddrey and MELD scores to assess the severity of alcohol-associated hepatitis and identify patients who may benefit from steroid therapy.
• Patients with a Maddrey score ≥32 or a high MELD score should be considered for steroid treatment, unless contraindications are present.
• The Lille score should be calculated on the seventh day of treatment to assess response to therapy and guide further management.

From the Research

Decision to Start Steroids for Acute Alcohol-Associated Hepatitis

The decision to start steroids for acute alcohol-associated hepatitis is based on several factors, including:

• Maddrey's discriminative function and MELD score, which are used to assess the severity of the disease 2, 3
• The patient's response to steroid therapy, which can be predicted by prothrombin time and other factors 4
• The risk of infection, which is increased in patients treated with prednisolone 5, 6

Key Factors in Deciding to Start Steroids

Some key factors to consider when deciding to start steroids for acute alcohol-associated hepatitis include:

• MELD score: a score between 21 and 51 is associated with improved survival with steroid therapy 3
• Maddrey's discriminative function: a score ≥32 defines severe alcohol-associated hepatitis, which may benefit from steroid therapy 2, 4
• Prothrombin time: a higher prothrombin time is associated with a lower response to steroid therapy 4
• Risk of infection: patients with a high risk of infection may not benefit from steroid therapy, and alternative treatments may be considered 5, 6

Data Most Helpful in Deciding to Start Steroids

The data most helpful in deciding to start steroids for acute alcohol-associated hepatitis are:

• Maddrey's discriminative function and MELD score, which provide information on the severity of the disease and the potential benefit of steroid therapy 2, 3
• Prothrombin time and other factors that predict response to steroid therapy 4
• Information on the risk of infection, which can help identify patients who may not benefit from steroid therapy 5, 6