What is the treatment for alcoholic hepatitis?

Treatment 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

Assessment of Disease Severity

Disease severity assessment is crucial for determining appropriate treatment:

• Use validated scoring systems:
  • Maddrey Discriminant Function (MDF): ≥32 indicates severe disease
  • MELD score: >20 indicates high 90-day mortality
  • Glasgow Alcoholic Hepatitis Score (GAHS): ≥9 indicates high 28-day mortality
  • ABIC score: Category C predicts high mortality 2, 1

Treatment Algorithm

1. Alcohol Abstinence

• Must be implemented for all patients regardless of disease severity
• Consider pharmacotherapy to support abstinence:
  • Naltrexone or acamprosate in combination with counseling 1
  • Baclofen may be beneficial for patients with cirrhosis 1

2. Nutritional Support

• Provide aggressive nutritional support:
  • Protein: 1.2-1.5 g/kg/day
  • Calories: 35-40 kcal/kg/day 2, 1
• If three meals are inadequate, add early morning and late night meals 2
• Consider feeding tube for patients with anorexia or altered mental status 1
• Supplement vitamins and minerals:
  • Vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 2, 1

3. Pharmacological Treatment for Severe Alcoholic Hepatitis (MDF ≥32)

• First-line therapy: Prednisolone 40 mg/day orally for 28 days 2, 1

  • Contraindications: uncontrolled infection, gastrointestinal bleeding, renal failure, pancreatitis 2, 1

• Assess response to steroids at day 7 using:

  • Lille model: Complete responders (≤0.16), partial responders (0.16-0.56), null responders (≥0.56)
  • Early Change in Bilirubin Level (ECBL): Bilirubin at day 7 lower than day 1 2, 1

• Management based on response:

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

• Alternative approach: N-acetylcysteine + corticosteroids may provide short-term benefit 1

• Important: Pentoxifylline is no longer recommended due to ineffectiveness based on recent evidence 1, 3

4. Infection Surveillance and Prevention

• Perform systematic microbiological examination before initiating corticosteroids:
  • Urine, ascites fluid, and blood cultures 1
• Monitor closely for infection during treatment 1

5. Management of Complications

• Monitor for complications of cirrhosis:
  • Ascites, hepatic encephalopathy, infections
• Avoid nephrotoxic drugs, including diuretics when possible 1

Special Considerations

Mild-Moderate Alcoholic Hepatitis

• Supportive care and abstinence only; no steroid therapy needed 1

Severe Disease with Contraindications to Steroids

• Focus on supportive care, nutritional support, and abstinence
• Consider evaluation for liver transplantation in highly selected patients 3

Prognosis and Long-term Outcomes

• Short-term (28-day) survival is improved with prednisolone, but medium and long-term survival benefits are not established 1
• 5-year survival rates: 80% with maintained abstinence vs. 50% with alcohol relapse 1
• The 1-year mortality rate was 56% in the STOPAH trial 2

Pitfalls to Avoid

• Failing to assess disease severity using validated scoring systems
• Initiating steroids without ruling out infection
• Neglecting nutritional support, which is essential for all patients
• Continuing steroids in null responders (Lille score ≥0.56)
• Using pentoxifylline as an alternative to steroids, as it has been shown to be ineffective 1, 3
• Overlooking the importance of long-term alcohol abstinence, which is the most important factor for improved survival 2, 1, 4