What are the recommendations for supportive care in patients with alcoholic hepatitis?

From the Guidelines

Supportive care for patients with alcoholic hepatitis should focus on nutritional support, alcohol abstinence, and management of complications, with corticosteroid therapy recommended for patients with severe forms, as defined by a Maddrey score ≥ 32 or MELD score > 20, as stated in the 2022 French Association for the Study of the Liver and the French Alcohol Society clinical guidelines 1. The management of alcoholic hepatitis requires a multifaceted approach, including:

• Nutritional support with a recommended daily caloric intake of 35-40 kcal/kg and protein intake of 1.2-1.5 g/kg, as recommended by the ESPEN guidelines on enteral nutrition: liver disease 1
• Complete alcohol abstinence, which is essential for recovery, and patients should be offered resources for alcohol use disorder treatment, including medications like acamprosate, naltrexone, or baclofen, as suggested by the medical management of severe alcoholic hepatitis: expert review from the Clinical Practice Updates Committee of the AGA Institute 1
• Management of complications, such as:

• Treating ascites with sodium restriction and diuretics, as recommended by the EASL clinical practice guidelines: management of alcohol-related liver disease 1
• Addressing hepatic encephalopathy with lactulose and rifaximin, as suggested by the medical management of severe alcoholic hepatitis: expert review from the Clinical Practice Updates Committee of the AGA Institute 1
• Monitoring for infections with low threshold for antibiotic initiation, as recommended by the EASL clinical practice guidelines: management of alcohol-related liver disease 1

• Assessment for coagulopathy and renal dysfunction, with appropriate interventions as needed, as suggested by the medical management of severe alcoholic hepatitis: expert review from the Clinical Practice Updates Committee of the AGA Institute 1 The use of corticosteroids, such as prednisolone or methylprednisolone, is recommended for patients with severe alcoholic hepatitis, as defined by a Maddrey score ≥ 32 or MELD score > 20, as stated in the 2022 French Association for the Study of the Liver and the French Alcohol Society clinical guidelines 1. The Lille score should be calculated on the seventh day of treatment to identify patients not responding to treatment, as recommended by the EASL clinical practice guidelines: management of alcohol-related liver disease 1. Some key points to consider in the management of alcoholic hepatitis include:
• The importance of early recognition and treatment, as the onset of jaundice indicates decompensation and is an ominous sign in all patients with chronic liver disease, particularly those with alcoholic liver disease, as stated in the medical management of severe alcoholic hepatitis: expert review from the Clinical Practice Updates Committee of the AGA Institute 1
• The need for a comprehensive approach that addresses the multifaceted nature of alcoholic hepatitis and targets the underlying pathophysiological processes of inflammation, malnutrition, and organ dysfunction, as suggested by the EASL clinical practice guidelines: management of alcohol-related liver disease 1
• The importance of patient education and support, including encouragement to abstain completely from drinking and offering support and encouragement even if they fail to achieve abstinence, as a reduction in alcohol consumption improves survival, as stated in the medical management of severe alcoholic hepatitis: expert review from the Clinical Practice Updates Committee of the AGA Institute 1.

From the Research

Supportive Care for Alcoholic Hepatitis

The recommendations for supportive care in patients with alcoholic hepatitis include:

• Corticosteroids, such as prednisolone, which have been shown to reduce short-term mortality in severe cases 2, 3, 4
• Pentoxifylline, which has been associated with a lower risk of hepatorenal syndrome and infection 2, 5
• A combination of corticosteroids and pentoxifylline, which may be considered for patients with severe alcoholic hepatitis 2

Treatment Considerations

When initiating treatment, it is recommended to:

• Evaluate patients thoroughly before starting steroids, and consider a delay of up to a week if necessary 3
• Use the lowest possible steroid exposure, with a two-week taper regimen 3
• Monitor patients closely for adverse events, such as infections, gastrointestinal bleeds, and renal impairment 3, 4

Emerging Therapies

New therapeutic approaches are being developed, including:

• Anti-inflammatory agents
• Modifications of the gut-liver axis and intestinal dysbiosis
• Epigenetic modulation
• Antioxidants
• Drugs targeting liver regeneration 6
• Early liver transplantation, which may be a safe treatment option for selected patients with severe alcoholic hepatitis not responding to medical treatment 6