What is the first step in treating acute alcoholic hepatitis?

First Step in Treatment for Acute Alcoholic Hepatitis

The first step in treating acute alcoholic hepatitis is to 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, while assessing disease severity using validated scoring systems such as the Maddrey Discriminant Function (MDF) and MELD score. 1

Initial Assessment and Management

1. Disease Severity Assessment:

   • Calculate Maddrey Discriminant Function (MDF) and MELD score to determine severity
   • Severe alcoholic hepatitis is defined as MDF ≥32 or MELD >20 1

2. Nutritional Intervention:

   • Systematically evaluate nutritional status
   • Provide protein intake of 1.2-1.5 g/kg/day
   • Ensure caloric intake of 35-40 kcal/kg/day
   • Supplement B-complex vitamins and other micronutrients (vitamin A, thiamine, B12, folate, pyridoxine, vitamin D, and zinc) 1
   • Consider enteral feeding if the patient cannot eat adequately

3. Infection Screening:

   • Perform systematic microbiological screening before initiating pharmacological treatment
   • Include blood cultures, urine cultures, and ascites fluid analysis 1

Pharmacological Treatment

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

• First-line treatment: Prednisolone 40 mg daily for 28 days 1
• Assess treatment response at day 7 using the Lille model:
  • Lille score <0.45 indicates response - continue treatment
  • Lille score ≥0.45 indicates non-response - consider stopping treatment 1

Alternative approaches:

• N-acetylcysteine + corticosteroids may provide short-term benefit 1
• Pentoxifylline is no longer recommended due to ineffectiveness 1, 2

Monitoring and Complication Management

• Monitor closely for infections, which significantly increase mortality risk 1, 3
• Watch for hepatorenal syndrome and avoid nephrotoxic drugs including diuretics when possible 1
• Monitor and manage complications of cirrhosis such as ascites and hepatic encephalopathy 1

Prognostic Considerations

• The benefit of corticosteroids is modest and limited to 28 days with no improvement in long-term survival 1, 4
• Long-term outcomes depend primarily on maintaining abstinence from alcohol 1, 4
• 5-year survival rates: 80% with maintained abstinence vs. 50% with alcohol relapse 1

Common Pitfalls and Caveats

• Failing to screen for infections before starting corticosteroids can lead to worse outcomes
• Underestimating the importance of nutritional support - malnutrition is common and worsens prognosis
• Relapse to alcohol use is reported in nearly half of patients who recover from alcoholic hepatitis 4
• The 1-year mortality rate was 56% in the STOPAH trial, highlighting the importance of early and aggressive treatment 1

While recent studies have explored alternative treatments including antioxidants 5, these have not shown superiority to corticosteroids for severe cases. The evidence consistently supports that the foundation of treatment begins with alcohol abstinence and nutritional support, followed by pharmacological intervention with corticosteroids in severe cases.