What is the first step in treating acute alcoholic hepatitis?

First-Line Treatment for Acute Alcoholic Hepatitis

The first step in treating acute alcoholic hepatitis is to assess disease severity, promote complete alcohol abstinence, and provide nutritional support with a target of 35-40 kcal/kg/day and 1.2-1.5 g/kg/day of protein. 1, 2

Assessment and Classification

Before initiating specific therapies, proper assessment is crucial:

1. Determine disease severity using validated scoring systems:

   • Maddrey Discriminant Function (MDF) ≥32 indicates severe disease
   • MELD score >20 also indicates severe disease
   • Glasgow Alcoholic Hepatitis Score ≥9

2. Screen for infections before initiating treatment:

   • Blood cultures
   • Urine cultures
   • Ascites fluid analysis (if present)
   • Chest X-ray

3. Rule out contraindications to specific treatments:

   • Uncontrolled infections
   • Acute kidney injury with serum creatinine >2.5 mg/dL
   • Uncontrolled gastrointestinal bleeding
   • Concomitant diseases (HBV, HCV, drug-induced liver injury, etc.)

Initial Management Steps

1. Alcohol Abstinence

• Complete abstinence is the cornerstone of therapy and the most important factor for long-term survival 2
• 5-year survival rates reach 80% with maintained abstinence versus 50% with alcohol relapse 2

2. Nutritional Support

• Systematic evaluation of nutritional status is essential 1
• Target 35-40 kcal/kg/day and protein intake of 1.2-1.5 g/kg/day 1, 2
• Prefer oral route as first-line nutritional intervention 1
• Consider enteral tube feeding if oral intake is inadequate 2
• Supplement with B-complex vitamins and other micronutrients 1, 2

3. Medical Therapy for Severe Disease

For patients with severe alcoholic hepatitis (MDF ≥32 or MELD >20):

• Prednisolone 40 mg daily for 28 days is the recommended first-line pharmacological treatment 1, 2
• Assess treatment response at day 7 using the Lille model:
  • Lille score <0.45: continue treatment for 28 days
  • Lille score ≥0.45: consider stopping treatment, particularly in null responders (Lille ≥0.56) 1

Important Considerations

• Infection prevention: Systematic microbiological screening before starting corticosteroids is crucial as infections increase mortality risk 2
• Renal protection: Avoid nephrotoxic drugs and monitor for development of hepatorenal syndrome 1, 2
• Monitoring: Close observation for complications of cirrhosis (ascites, hepatic encephalopathy) 2
• Treatment limitations: The benefit of corticosteroids is modest and limited to 28-day mortality without improvement in long-term survival 2

Pitfalls to Avoid

1. Delaying nutritional support - Inadequate caloric intake (<21.5 kcal/kg/day) significantly increases mortality risk 1
2. Missing infections - Infections are common (12-26% at admission) and may not always present with fever 1
3. Overlooking renal function - AKI significantly worsens prognosis and requires prompt attention 1
4. Continuing steroids in non-responders - Continuing steroids in patients with Lille score ≥0.45 at day 7 increases risk without benefit 1, 2
5. Focusing only on short-term management - Long-term abstinence counseling is essential for survival 2

For patients who fail medical therapy, early liver transplantation may be considered in carefully selected candidates with good insight into their alcohol use disorder and strong social support 2.