Treatment of Alcoholic Hepatitis
The treatment of alcoholic hepatitis should be stratified based on disease severity, with severe cases (MDF ≥32) requiring prednisolone 40 mg/day for 28 days as first-line therapy, while mild-moderate cases primarily need alcohol abstinence and nutritional support. 1
Disease Severity Assessment
Disease severity must be determined using validated scoring systems:
- Maddrey Discriminant Function (MDF): Score ≥32 indicates severe disease
- MELD score: >20 indicates high mortality risk
- Glasgow Alcoholic Hepatitis Score (GAHS): ≥9 indicates high mortality risk
- ABIC score: Category C indicates high mortality risk
These scores help stratify patients and guide therapeutic decisions 1.
Treatment Algorithm
1. Mild-Moderate Alcoholic Hepatitis (MDF <32)
- Complete alcohol abstinence (critical for survival)
- Nutritional support
- Monitor closely without specific pharmacological interventions 2
- Address vitamin and mineral deficiencies
2. Severe Alcoholic Hepatitis (MDF ≥32)
First-line therapy:
- Prednisolone 40 mg/day orally for 28 days (if no contraindications) 1
- Contraindications to steroids include:
- Uncontrolled infection
- Gastrointestinal bleeding
- Renal failure
- Pancreatitis
Response assessment:
- Evaluate response at day 7 using Lille model:
- Complete responders (Lille ≤0.16): Continue prednisolone for full 28 days
- Partial responders (Lille 0.16-0.56): Continue prednisolone for full 28 days
- Null responders (Lille ≥0.56): Consider discontinuing steroids and evaluate for liver transplantation 1
Alternative approaches:
- N-acetylcysteine + corticosteroids may provide short-term benefit 1
- Pentoxifylline is no longer recommended due to ineffectiveness in recent studies 1
3. Nutritional Support (All Patients)
- Protein intake: 1.2-1.5 g/kg/day
- Caloric intake: 35-40 kcal/day
- Consider early morning and late night meals if three meals are inadequate
- Supplement vitamins and minerals (vitamin A, thiamine, B12, folate, pyridoxine, vitamin D, zinc) 1
4. Liver Transplantation
- Early liver transplantation may be considered for carefully selected patients with severe alcoholic hepatitis who fail medical therapy 3
- Provides significant survival benefit with 6-month survival rates of 77-100% 3
- Traditionally requires 6 months of abstinence, but this requirement may be reconsidered in select cases 3
Management of Complications
- Infections: Perform systematic microbiological examination (urine, ascites fluid, blood cultures) before initiating corticosteroids 1
- Renal complications: Avoid nephrotoxic drugs including diuretics when possible 1
- Portal hypertension complications: Monitor and treat ascites, hepatic encephalopathy, and variceal bleeding 1
Prognosis and Long-term Management
- One-year mortality rate is approximately 56% in severe alcoholic hepatitis 1
- Long-term outcomes depend primarily on maintaining abstinence:
- 5-year survival: 80% with maintained abstinence vs. 50% with alcohol relapse 1
- Consider naltrexone or acamprosate in combination with counseling to decrease relapse likelihood 1
Common Pitfalls to Avoid
- Failure to assess disease severity: Always calculate MDF or other validated scores to guide treatment
- Delayed treatment initiation: Promptly start corticosteroids in severe cases without contraindications
- Inadequate nutritional support: Malnutrition worsens outcomes and must be aggressively addressed
- Missing infections: Screen thoroughly for infections before starting steroids
- Neglecting addiction treatment: Long-term survival depends on abstinence
The management of alcoholic hepatitis requires a comprehensive approach addressing both the acute liver injury and the underlying alcohol use disorder, with disease severity guiding specific interventions.