From the Guidelines
The treatment for acute alcoholic hepatitis primarily involves complete alcohol cessation and supportive care, with corticosteroids like methylprednisolone 32 mg daily for 1 month being the first-line therapy for severe cases, as recommended by the most recent and highest quality study 1.
Key Components of Treatment
- Complete alcohol cessation is the cornerstone of treatment for acute alcoholic hepatitis, as emphasized in 1 and 1.
- Corticosteroids, such as methylprednisolone, are recommended for severe cases, defined by a Maddrey discriminant function (MDF) score > 32 or a MELD score > 20, as indicated in 1 and 1.
- Nutritional support is crucial, with a recommended protein intake of 1-1.5 g/kg/day and 30-40 kcal/kg/day, as suggested in 1.
- Vitamin supplementation, particularly thiamine, folate, and multivitamins, helps address common deficiencies, as noted in 1 and 1.
Management of Complications
- Infections should be treated with appropriate antibiotics, as emphasized in 1.
- Ascites should be addressed with sodium restriction and diuretics, as suggested in 1 and 1.
- Hepatic encephalopathy should be managed with lactulose, as recommended in 1 and 1.
Consideration for Liver Transplantation
- For patients with severe disease who do not respond to medical therapy, early liver transplantation may be considered after a period of sobriety, typically 6 months, as indicated in 1 and 1.
Assessment and Monitoring
- The Lille score should be calculated on the seventh day of treatment to identify patients not responding to treatment, as recommended in 1.
- The MELD score and other prognostic models can help assess the severity of the disease and predict mortality, as noted in 1 and 1.
From the Research
Treatment for Acute Alcoholic Hepatitis
The treatment for acute alcoholic hepatitis involves various approaches, including:
- Corticosteroids: These have been the standard-of-care therapy, albeit controversial 2. However, recent studies have shown that prednisolone was not associated with a significant reduction in 28-day mortality 2.
- Pentoxifylline: This has been shown to be effective in severe alcoholic hepatitis, with some studies suggesting it may be superior to prednisolone 3, 4.
- Combination therapy: The combination of pentoxifylline and prednisolone has been studied, but it yields no additional benefit in terms of mortality and morbidity compared to pentoxifylline monotherapy 3.
- Liver transplantation: This should be offered to select patients with severe alcoholic hepatitis who are nonresponsive to medical treatment 2.
- New paradigms: A paradigm shift from anti-inflammatory therapy to liver regeneration treatment, such as granulocyte-colony stimulating factor, molecular targeted treatments, and fecal microbiota transplantation, is taking place 2.
Corticosteroid Use
Corticosteroids have been shown to improve survival in patients with severe alcoholic hepatitis, particularly those with MELD scores between 21 and 51 5. The maximum effect of corticosteroid treatment is observed with MELD scores between 25 and 39 5. However, no corticosteroid benefit is seen in patients with MELD >51 5.
Key Findings
- Severe alcoholic hepatitis is defined by modified Maddrey discriminant function ≥32 or Model for End-Stage Liver Disease (MELD) >21 and/or hepatic encephalopathy 2.
- Patients with severe alcoholic hepatitis need combined, i.e., static (MELD score) and dynamic (Lille's score), prognostication 2.
- Systemic inflammation and poor regeneration are hallmarks of severe alcoholic hepatitis, rather than intrahepatic inflammation 2.
- Corticosteroids improve short-term survival of patients with severe biopsy-proved alcoholic hepatitis 6.