From the Guidelines
For patients with moderate to severe alcoholic hepatitis, the recommended steroid regimen is prednisolone 40 mg daily (or methylprednisolone 32 mg daily) for 28 days, followed by a taper over 2-4 weeks, as supported by the most recent and highest quality study 1.
Key Considerations
- Treatment should be initiated in patients with a Maddrey's Discriminant Function score ≥32 or with hepatic encephalopathy, indicating severe disease.
- Before starting steroids, infection should be ruled out with blood cultures, chest imaging, and other appropriate tests as infections are a contraindication to steroid therapy.
- Response to treatment should be assessed after 7 days using the Lille score; if the score is >0.45, indicating non-response, steroids should be discontinued to avoid unnecessary side effects.
- Nutritional support should be provided alongside steroid therapy, and patients must completely abstain from alcohol.
- Steroids work by reducing inflammation in the liver through inhibition of pro-inflammatory cytokines and immune-mediated hepatocellular injury, which helps improve liver function and survival in responders.
Alternative Therapies
- Pentoxifylline (400 mg three times daily) may be considered as an alternative in patients with contraindications to steroids, though it's generally less effective, as noted in 1 and 1.
Recent Guidelines
- The French Association for the Study of the Liver and the French Alcohol Society clinical guidelines 1 and the American Association for the Study of Liver Diseases practice guidance 1 support the use of corticosteroids in patients with severe alcoholic hepatitis.
- The guidelines also emphasize the importance of assessing disease severity, providing nutritional support, and promoting abstinence from alcohol.
Patient Selection
- Patients with severe alcoholic hepatitis should be carefully selected for treatment, taking into account their overall health, presence of contraindications, and potential for response to therapy, as discussed in 1 and 1.
From the Research
Steroid Dosing for Alcoholic Hepatitis
- The recommended steroid dosing for patients with moderate to severe alcoholic hepatitis is prednisolone 40 mg daily for 28 days, as reported in a systematic review of randomized controlled trials 2.
- A study comparing pentoxifylline and prednisolone found that prednisolone 40 mg daily was associated with a higher 1-month survival rate (88.1% vs 75.8%) 3.
- Another study found that methylprednisolone 32 mg daily for 28 days, tapered over 2 weeks, decreased short-term mortality in patients with severe alcoholic hepatitis 4.
Adverse Events and Tapering Regimens
- Adverse events associated with steroid therapy in alcoholic hepatitis include infections, gastrointestinal bleeds, and renal impairment, with most infections occurring within the first month of treatment 2.
- A two-week steroid taper is commonly used, and it is recommended to use the lowest possible steroid exposure with close outpatient follow-up 2.
- The timing of steroid initiation and tapering regimens may vary, but it is recommended to take up to a week to evaluate patients before initiating steroids and to monitor them vigilantly in the first month of treatment 2.
Comparison of Steroid Therapies
- Corticosteroids, such as prednisolone and methylprednisolone, are commonly used to treat severe alcoholic hepatitis, and they have been shown to reduce short-term mortality 3, 4.
- Pentoxifylline has also been studied as a treatment for severe alcoholic hepatitis, but its efficacy is not statistically equivalent to that of prednisolone 3, 5.
- The choice of steroid therapy and dosing regimen may depend on individual patient factors and the severity of the disease 6.