What are the treatment recommendations for alcoholic hepatitis?

Management of Alcoholic Hepatitis

Complete alcohol abstinence is the cornerstone of treatment for alcoholic hepatitis and must be strictly recommended to all patients, as continued alcohol use is associated with disease progression and poor outcomes. 1, 2

Assessment of Disease Severity

Disease severity should be evaluated using validated scoring systems:

• Maddrey Discriminant Function (MDF): Score ≥32 indicates severe disease
• MELD score: Score >20-21 indicates high mortality risk
• Glasgow Alcoholic Hepatitis Score (GAHS): Score ≥9 indicates high mortality risk
• ABIC score: Category C predicts high mortality

Treatment Algorithm Based on Disease Severity

Severe Alcoholic Hepatitis (MDF ≥32 or MELD >20)

1. Corticosteroid therapy:

   • Prednisolone 40 mg/day orally or methylprednisolone 32 mg/day for 28 days 1, 2
   • Contraindications: uncontrolled infection, gastrointestinal bleeding, renal failure, pancreatitis 1, 2

2. Response assessment at day 7:

   • Use Lille model or Early Change in Bilirubin Level (ECBL)
   • Complete responders (Lille ≤0.16): continue prednisolone for 28 days
   • Partial responders (Lille 0.16-0.56): continue prednisolone for 28 days
   • Null responders (Lille ≥0.56): consider discontinuing steroids and evaluate for liver transplantation 2

3. Alternative approaches:

   • N-acetylcysteine + corticosteroids can be considered (shows short-term benefit) 1
   • Pentoxifylline is no longer recommended due to ineffectiveness 2

Mild to Moderate Alcoholic Hepatitis (MDF <32 or MELD ≤20)

• Supportive care and abstinence only
• No steroid therapy needed 2

Supportive Care for All Patients

1. Nutritional support:

   • Protein intake: 1.2-1.5 g/kg/day (increase to 1.5 g/kg/day if critically ill)
   • Caloric intake: 35-40 kcal/kg/day
   • Consider feeding tube for patients unable to eat due to anorexia or altered mental status 1, 2
   • If three meals per day are inadequate, consider additional smaller meals 1

2. Vitamin and mineral supplementation:

   • Provide vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 1

3. Infection surveillance:

   • Systematic microbiological examination (urine, ascites fluid, blood cultures) before initiating corticosteroids 1
   • Monitor closely for infection during treatment

4. Alcohol abstinence support:

   • Consider naltrexone or acamprosate in combination with counseling to decrease relapse risk 1, 2
   • One study suggested benefit with baclofen in patients with cirrhosis 1

Monitoring and Follow-up

• Closely monitor for complications of cirrhosis (ascites, hepatic encephalopathy, infections)
• Avoid nephrotoxic drugs including diuretics when possible, as acute kidney injury is an early manifestation of multi-organ failure 1
• Presence of systemic inflammatory response syndrome (SIRS) on admission indicates increased risk of multi-organ failure 1

Long-term Management

• Long-term outcomes depend primarily on maintaining abstinence 1, 3
• 5-year survival rates: 80% with maintained abstinence vs. 50% with alcohol relapse 1
• Addiction treatment must be systematically offered after an episode of alcoholic hepatitis 1

Important Caveats

• While corticosteroids improve short-term (28-day) survival, they have not shown medium or long-term survival benefits 1, 2
• The combination of Lille and MELD scores provides optimal approach for evaluating short and medium-term mortality risk 1
• Patients with alcoholic hepatitis are particularly prone to infections and malnutrition, which should be aggressively identified and treated 3