What is the next step in managing a patient with alcoholic hepatitis who was discharged on steroids but has since relapsed into alcohol consumption?

Management of Alcoholic Hepatitis in a Patient Who Has Resumed Drinking After Steroid Treatment

The most important next step for a patient with alcoholic hepatitis who was discharged on steroids but has resumed drinking is to immediately implement a comprehensive alcohol abstinence program including both pharmacologic therapy (baclofen or acamprosate) and psychosocial interventions. 1

Immediate Assessment and Management

1. Evaluate current liver function:

   • Assess for worsening hepatitis with liver function tests
   • Calculate MELD score to determine disease severity
   • Screen for complications (ascites, encephalopathy, infections)

2. Discontinue steroids if still taking them:

   • Continued alcohol use with steroids increases risk of complications
   • Steroids are ineffective without abstinence

Alcohol Abstinence Strategy

Pharmacologic Interventions

• First-line medication: Initiate baclofen (GABA-B receptor agonist)

  • Demonstrated benefit in patients with cirrhosis for achieving and maintaining abstinence 1
  • Starting dose: 5-10 mg three times daily, titrated as needed

• Alternative option: Acamprosate

  • FDA-approved for maintenance of alcohol abstinence 2
  • Dosage: 666 mg (two 333 mg tablets) three times daily 2
  • Must be initiated after alcohol withdrawal when patient has achieved abstinence 2
  • Requires dose adjustment for moderate renal impairment; contraindicated in severe renal impairment 2

Psychosocial Interventions

• Implement FRAMES model for brief intervention 1:

  • Feedback about dangers of continued drinking
  • Responsibility emphasis on patient's choices
  • Advice for abstinence
  • Menu of alternatives
  • Empathy with the patient's perspective
  • Self-efficacy encouragement

• Referral to support programs:

  • Alcoholics Anonymous or similar group therapy 1
  • Individual psychotherapy with cognitive behavioral approach
  • Family therapy and education 1

Nutritional Support

• Provide nutritional assessment and support:
  • Protein intake: 1.2-1.5 g/kg/day
  • Caloric intake: 35-40 kcal/kg/day
  • Consider branched-chain amino acid supplementation if malnourished 1
  • More frequent smaller meals if needed to achieve adequate intake 1

Monitoring and Follow-up

1. Close monitoring schedule:

   • Weekly liver function tests initially
   • Regular assessment of alcohol abstinence
   • Screening for complications of alcoholic liver disease

2. Consider liver transplantation evaluation if:

   • Patient demonstrates commitment to abstinence
   • Liver function continues to deteriorate despite abstinence 1

Important Caveats

• Alcohol abstinence is the cornerstone of treatment - Without it, other therapies will have limited effectiveness 1

• Relapse is common - Up to 40% of patients may relapse, requiring ongoing support and monitoring 1

• Avoid re-initiating steroids while patient is actively drinking - This may increase risk of infections, particularly fungal infections 3

• Recognize the therapeutic window for steroids - Steroids are most effective for MELD scores between 25-39; outside this range, benefits may be limited 4

• Combined approach may be beneficial - Some evidence suggests that nutritional therapy combined with shorter steroid courses may be beneficial once abstinence is re-established 5