When to consider steroids in alcoholic hepatitis?

From the Guidelines

Corticosteroids should be considered in patients with severe alcoholic hepatitis, defined as a Maddrey's Discriminant Function (MDF) score ≥32 or the presence of hepatic encephalopathy, as they have been shown to improve short-term survival in these patients. The standard regimen is prednisolone 40 mg daily for 28 days, followed by a taper over 2-4 weeks. Alternatively, methylprednisolone 32 mg daily can be used. Before starting steroids, patients should be screened for contraindications including active infection, gastrointestinal bleeding, renal failure, or pancreatitis. A Lille score should be calculated after 7 days of treatment; if the score is >0.45, indicating non-response, steroids should be discontinued to avoid unnecessary side effects. Some key points to consider when treating patients with severe alcoholic hepatitis include:

• The use of corticosteroids, such as prednisolone or methylprednisolone, to reduce inflammation and improve survival rates 1
• The importance of calculating the Lille score after 7 days of treatment to identify non-responders and discontinue steroids if necessary 1
• The need for careful patient selection and monitoring for infections, hyperglycemia, and other steroid-related complications 1
• The consideration of alternative treatments, such as pentoxifylline, for patients with contraindications to steroids, although its effectiveness is still debated 1
• The importance of complete abstinence from alcohol and nutritional support alongside steroid therapy 1
• The potential benefits of combining corticosteroids with other treatments, such as N-acetylcysteine, although more research is needed to confirm this 1
• The use of the MELD score and other prognostic scores to identify patients at high risk of mortality and prioritize treatment 1

From the Research

Consideration of Steroids in Alcoholic Hepatitis

When considering steroids in alcoholic hepatitis, several factors should be taken into account:

• The severity of the disease, as measured by the Model for End-Stage Liver Disease (MELD) score or the Maddrey discriminant function 2, 3, 4, 5
• The presence of hepatic encephalopathy or other complications 2
• The potential benefits and risks of steroid therapy, including the risk of infection and multiple organ failure 2, 6

Indications for Steroid Therapy

Steroid therapy may be considered in patients with:

• Severe alcoholic hepatitis, defined by a MELD score >20 or a Maddrey discriminant function ≥32 2, 3, 6
• A MELD score between 21 and 51, as this range has been shown to have a significant survival benefit with steroid therapy 3
• A MELD score between 25 and 39, as this range has been shown to have the maximum effect of corticosteroid treatment 3

Contraindications for Steroid Therapy

Steroid therapy may not be beneficial in patients with:

• Very severe liver disease, as defined by a MELD score >51 3
• Infection or multiple organ failure, as steroid therapy may exacerbate these conditions 2, 6

Alternative Therapies

Alternative therapies, such as pentoxifylline, granulocyte-colony stimulating factor, molecular targeted treatments, and fecal microbiota transplantation, may be considered in patients who are not responsive to steroid therapy or have contraindications to steroid use 2, 6