From the Guidelines
The recommended prednisolone dose for alcoholic hepatitis is 40 mg daily for 28 days. Specifically:
- Start with oral prednisolone 40 mg once daily in the morning
- Continue this dose for 28 days
- After 28 days, taper the dose gradually over 2-4 weeks Additional important points:
- Only use in severe alcoholic hepatitis (defined as Maddrey's Discriminant Function >32) 1
- Assess response after 7 days; if no improvement, consider stopping treatment 1
- Screen for infections before starting, as steroids can worsen existing infections
- Monitor blood glucose closely, as steroids can cause hyperglycemia Prednisolone is used because it reduces inflammation in the liver and suppresses the overactive immune response seen in alcoholic hepatitis, as shown in recent studies 1. The 28-day duration is based on clinical trials showing optimal benefit with this treatment length 1. The morning dosing helps mimic the body's natural cortisol rhythm and may reduce side effects.
The most recent and highest quality study, published in 2022, confirms the effectiveness of corticosteroid therapy, including prednisolone, in improving short-term survival in patients with severe alcoholic hepatitis 1. This study, along with others, supports the use of prednisolone 40 mg/day for 28 days as the recommended treatment for severe alcoholic hepatitis.
It is essential to note that the use of prednisolone should be limited to patients with severe alcoholic hepatitis, and the treatment should be carefully monitored to minimize potential side effects and complications. The combination of N-acetylcysteine and corticosteroids may also be considered, but more studies are needed to confirm its effectiveness 1. Pentoxifylline is no longer recommended due to its ineffectiveness in improving survival in patients with severe alcoholic hepatitis 1. Fast-track liver transplantation may be considered for patients who do not respond to medical treatment, but the selection process should be rigorous and multidisciplinary 1.
From the Research
Recommended Dose of Prednisolone for Alcoholic Hepatitis
- The recommended dose of Prednisolone for the treatment of alcoholic hepatitis is 40 mg/day for 28 days 2, 3, 4, 5, 6.
- This dose has been used in several studies, including a randomized clinical trial that compared the effectiveness of Prednisolone with and without Pentoxifylline in patients with severe alcoholic hepatitis 5.
- Another study, a 2 × 2 factorial randomised controlled trial, also used a dose of 40 mg/day for 28 days and found that Prednisolone reduced the risk of mortality at 28 days, but this benefit was not sustained beyond 28 days 6.
Treatment Duration and Response
- The treatment duration for Prednisolone in alcoholic hepatitis is typically 28 days 2, 3, 4, 5, 6.
- The response to treatment is often assessed using the Lille model, which defines treatment nonresponders after 7 days of initiation of treatment 2, 5.
- Patients who do not respond to treatment may have a higher risk of mortality and may require alternative treatments or interventions 5.
Combination Therapy
- Some studies have investigated the use of combination therapy with Prednisolone and other agents, such as Pentoxifylline or S-adenosylmethionine (SAMe) 2, 4, 5, 6.
- The results of these studies have been mixed, with some showing improved outcomes with combination therapy and others showing no benefit 2, 4, 5, 6.