From the Guidelines
Corticosteroids, specifically prednisolone 40 mg/day or methylprednisolone 32 mg/day, are recommended for patients with severe alcoholic hepatitis, as they improve short-term survival without any observations of a medium- or long-term survival benefit.
Patient Selection
Patient selection is crucial when considering corticosteroid therapy for alcoholic hepatitis. The following criteria should be met:
- Severe alcoholic hepatitis, as indicated by a high Maddrey's Discriminant Function score or MELD score
- No active infection
- No gastrointestinal bleeding within the past week
- No renal failure
Treatment Regimen
The typical treatment regimen for corticosteroids in severe alcoholic hepatitis is prednisolone 40 mg/day or methylprednisolone 32 mg/day for 1 month, as recommended by the French Association for the Study of the Liver and the French Alcohol Society clinical guidelines 1.
Monitoring and Risks
Before starting treatment, patients should be screened for infections, including blood cultures and chest X-ray, and monitored closely for infections during treatment, as corticosteroids increase infection risk. The benefits of corticosteroid therapy must be weighed against the risks, particularly infections.
Alternative Therapies
Pentoxifylline is no longer recommended as an alternative or add-on therapy for severe alcoholic hepatitis, as several recent randomized studies and meta-analyses have shown that it does not improve 1-month survival 1.
Additional Recommendations
Absolute alcohol cessation is essential for any treatment to be effective, and patients should be referred for alcohol cessation counseling and support alongside medical treatment. A careful evaluation of nutritional status should be performed, and patients should aim to achieve a daily energy intake ≥35–40 kcal/kg BW and 1.2–1.5 g/kg protein, with the oral route as the first-line intervention 1.
Recent Guidelines
Recent guidelines from the European Association for the Study of the Liver (EASL) recommend the use of corticosteroids in patients with severe alcoholic hepatitis, as well as the combination of N-acetylcysteine with corticosteroids in selected patients 1.
Key Points
- Corticosteroids improve short-term survival in severe alcoholic hepatitis
- Patient selection is crucial, with criteria including severe disease, no active infection, and no gastrointestinal bleeding or renal failure
- Treatment regimen: prednisolone 40 mg/day or methylprednisolone 32 mg/day for 1 month
- Monitor for infections and weigh benefits against risks
- Absolute alcohol cessation and nutritional support are essential components of treatment.
From the Research
Role of Corticosteroids in Alcoholic Hepatitis
- Corticosteroids, such as prednisolone, are commonly used in the treatment of severe alcoholic hepatitis, providing a modest survival benefit 2, 3, 4.
- The use of corticosteroids has been shown to improve short-term survival in patients with severe alcoholic hepatitis, with a reduction in 28-day mortality 3, 4.
- However, the long-term benefits of corticosteroids are less clear, with some studies suggesting no significant improvement in outcomes at 90 days or 1 year 3.
Combination Therapy
- Combination therapy with corticosteroids and other agents, such as granulocyte colony-stimulating factor (GCSF) or S-adenosylmethionine (SAMe), may improve treatment outcomes in severe alcoholic hepatitis 2, 5.
- The addition of GCSF to prednisolone has been shown to improve steroid responsiveness and 90-day survival, with fewer infections and new onset complications 2.
- The combination of prednisolone and SAMe has been associated with a better therapy response and less frequent hepatorenal syndrome occurrence 5.
Adverse Events
- Corticosteroids are associated with an increased risk of adverse events, including infections, gastrointestinal bleeds, and renal impairment 6, 3.
- The risk of serious infections is higher in patients treated with prednisolone, particularly in the first month of treatment 6, 3.
- Close monitoring and vigilant surveillance are recommended to minimize the risk of adverse events 6.