What is the treatment for decompensated alcoholic liver disease?

From the Guidelines

The treatment for decompensated alcoholic liver disease requires immediate alcohol cessation and comprehensive medical management, with corticosteroids, such as prednisolone 40 mg daily for 28 days, recommended for patients with severe alcoholic hepatitis (Maddrey's Discriminant Function >32) 1. Patients should be hospitalized for close monitoring and supportive care. Nutritional support is essential, with a high-calorie (35-40 kcal/kg/day), high-protein (1.2-1.5 g/kg/day) diet, along with vitamin supplementation including thiamine (100 mg daily), folate (1 mg daily), and multivitamins. Management of complications is crucial:

• diuretics (spironolactone 100-400 mg/day with furosemide 40-160 mg/day) for ascites
• prophylactic antibiotics like norfloxacin 400 mg daily for spontaneous bacterial peritonitis prevention
• lactulose (30-60 ml every 6-8 hours) and rifaximin (550 mg twice daily) for hepatic encephalopathy
• and endoscopic band ligation or propranolol (starting at 20 mg twice daily, titrated to heart rate) for variceal bleeding. Addressing alcohol use disorder with counseling and medications such as acamprosate, naltrexone, or baclofen is vital for long-term recovery. In end-stage disease, liver transplantation may be considered after a period of abstinence, typically 6 months, though this requirement varies between transplant centers 1. Pentoxifylline is no longer recommended due to its ineffectiveness 1. Fast-track liver transplantation should be considered for patients at the end of their therapeutic options, with a rigorous and multidisciplinary selection process 1. The combined MELD+Lille score is recommended for the selection of patients with the highest death risk 1.

Some key points to consider in the treatment of decompensated alcoholic liver disease include:

• The importance of abstinence from alcohol, as it is the cornerstone of treatment for alcoholic hepatitis 1
• The use of corticosteroids, such as prednisolone, in patients with severe alcoholic hepatitis 1
• The management of complications, such as ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy 1
• The consideration of liver transplantation in patients with end-stage disease, after a period of abstinence 1

From the Research

Diagnosis of Decompensated Alcoholic Liver Disease

• Decompensated alcoholic liver disease is characterized by jaundice and liver impairment in patients with a history of heavy and prolonged alcohol use 2.
• The diagnosis of decompensated alcoholic liver disease can be made based on clinical findings, including rapid onset of jaundice and a high risk of mortality 3.
• The modified discriminant function score and Model for End-Stage Liver Disease (MELD) score can be used to assess the severity of alcoholic hepatitis and predict mortality 3.

Treatment of Decompensated Alcoholic Liver Disease

• Corticosteroid therapy is associated with improved 1-month survival in patients with severe alcoholic hepatitis, and may be considered as a first-line treatment option 2, 3, 4.
• Pentoxifylline may be considered as a second-line treatment option for patients with severe alcoholic hepatitis who are not responsive to corticosteroids or have contraindications to corticosteroid use 2, 4.
• Liver transplantation may be considered for patients with decompensated liver disease who do not respond to medical therapy, and may be the most effective therapy for patients with severe liver dysfunction 3, 5.
• Abstinence from alcohol is essential for the management of decompensated alcoholic liver disease, and patients who are abstinent have a better prognosis than those who continue to drink 3, 5.

Prognosis and Outcome

• The prognosis for patients with decompensated alcoholic liver disease is generally poor, with high mortality rates at 6 and 12 months 6.
• The requirement for organ support measures, such as ventilation or renal replacement therapy, is associated with a poor prognosis and high mortality rates 6.
• Early liver transplantation may be considered for highly select patients with severe alcoholic hepatitis who do not respond to medical therapy, and may improve survival rates 3.