What is the recommended dose of prednisolone (corticosteroid) for patients with severe alcoholic hepatitis as indicated by the Maddrey discriminant function?

Prednisolone Dosing for Severe Alcoholic Hepatitis Based on Maddrey Discriminant Function

For patients with severe alcoholic hepatitis as indicated by a Maddrey discriminant function (MDF) score ≥32, the recommended dose is prednisolone 40 mg daily for 28 days, followed by either discontinuation or a 2-week taper depending on clinical response. 1, 2

Determining Severity and Treatment Eligibility

• Severe alcoholic hepatitis is defined as:

  • MDF score ≥32 (calculated as 4.6 × [patient's PT - control PT in seconds] + serum bilirubin in mg/dL)
  • With or without hepatic encephalopathy 1, 2

• Treatment contraindications include:

  • Uncontrolled infection
  • Gastrointestinal bleeding
  • Renal failure
  • Pancreatitis 1

Treatment Algorithm

1. For severe alcoholic hepatitis (MDF ≥32) WITHOUT contraindications:

   • Prednisolone 40 mg orally daily for 28 days 1, 2
   • Assess response at 7 days using Lille model or Early Change in Bilirubin Level (ECBL)

2. Response assessment at 7 days:

   • Complete responders (Lille score ≤0.16): Continue prednisolone for full 28 days
   • Partial responders (Lille score 0.16-0.56): Continue prednisolone for full 28 days
   • Null responders (Lille score ≥0.56): Consider discontinuing steroids and evaluate for liver transplantation 1, 2

3. After 28 days:

   • Either discontinue prednisolone or
   • Implement a 2-week taper depending on clinical response 1, 2

Alternative Treatments

• For patients with contraindications to steroids:
  • Historically, pentoxifylline 400 mg orally three times daily for 28 days was recommended 1
  • However, recent evidence indicates pentoxifylline is no longer recommended due to ineffectiveness 1, 3

Important Considerations

• While prednisolone improves short-term (28-day) survival, it has not shown medium or long-term survival benefits 1, 3
• Serious infections occur in approximately 13% of patients treated with prednisolone versus 7% in those not receiving prednisolone (p=0.002) 3
• The Lille model is crucial for determining early response to therapy and guiding treatment decisions 1, 2
• The 6-month survival rate is significantly higher for patients with a Lille score <0.45 than for those with a Lille score ≥0.45 4

Additional Management

• Complete alcohol abstinence is critical for long-term survival 1
• Aggressive nutritional support should be provided (protein 1.2-1.5 g/kg/day, calories 35-40 kcal/kg/day) 1
• Vitamin and mineral supplementation should be provided alongside nutritional therapy 1

The evidence strongly supports prednisolone 40 mg daily for 28 days as the standard treatment for severe alcoholic hepatitis, with response assessment at 7 days to guide continuation of therapy.