From the Guidelines
Steroid therapy with prednisolone should be initiated as soon as possible after diagnosis in eligible patients with severe alcoholic hepatitis, typically within 24-48 hours. The standard regimen is oral prednisolone 40mg daily for 28 days, followed by a tapering schedule over 2-4 weeks to prevent adrenal insufficiency. Before starting treatment, patients should be screened for contraindications including active infection, gastrointestinal bleeding, renal failure, or hepatitis B 1.
Key Considerations
- Steroids work by reducing inflammation in the liver by suppressing pro-inflammatory cytokines and immune responses that contribute to hepatocyte damage.
- Treatment is most beneficial for patients with severe disease, typically defined as those with a Maddrey's Discriminant Function score ≥32 or MELD score >20 1.
- Early response to therapy, assessed after 7 days using the Lille score, helps determine whether to continue the full course or discontinue treatment in non-responders.
- Patients should also receive nutritional support, thiamine supplementation, and management of alcohol withdrawal symptoms concurrently with steroid therapy.
Important Guidelines
- The Lille score must be calculated on the seventh day of treatment to identify patients not responding to treatment 1.
- Patients with a Lille score ≥ 0.45 are considered treatment non-responders and corticosteroid therapy must be stopped in those with a Lille score ≥0.56 1.
- Combining the Lille and MELD scores is the optimal approach for evaluating short- and medium-term risk of death 1.
- Long-term outcomes depend mainly on achieving abstinence, and addiction treatment must be systematically offered after an episode of alcoholic hepatitis 1.
From the Research
Timing of Steroid Initiation
- The timing of steroid initiation in patients with alcoholic hepatitis is crucial, and the evidence suggests that it can be initiated soon after diagnosis [ 2 ].
- A systematic review of randomized controlled trials found that the median time from admission to steroid initiation was 6.5 days [ 2 ].
- However, another study recommends taking up to a week to systematically and thoroughly evaluate patients before initiating steroids [ 2 ].
Steroid Therapy Regimen
- The most common steroid dosing regimen is prednisolone 40 mg daily for 28 days [ 2 ].
- A two-week steroid taper is the most frequently reported regimen [ 2 ].
- One study found that tapering of prednisolone dose could be started after a mean of 15.4 days [ 3 ].