What is the treatment for alcoholic hepatitis?

Treatment of Alcoholic Hepatitis

The cornerstone of alcoholic hepatitis treatment is complete alcohol abstinence, followed by corticosteroids (prednisolone 40 mg daily for 28 days) for severe cases with Maddrey Discriminant Function (mDF) ≥32 or MELD score >20. 1, 2

Disease Assessment and Severity Stratification

Diagnostic Criteria

• Onset of jaundice within 8 weeks of last alcohol consumption
• History of heavy drinking (>40g/day) for >6 months
• Serum bilirubin >3.0 mg/dL
• AST >50 IU/L but <400 IU/L
• AST/ALT ratio >1.5 1

Severity Assessment

Use validated scoring systems to determine treatment approach:

• mDF score ≥32: Indicates severe disease with high 28-day mortality
• MELD score >20: Predicts high 90-day mortality
• Glasgow alcoholic hepatitis score ≥9: Predicts high 28-day mortality 1, 2

Treatment Algorithm

1. First-Line Interventions (All Patients)

• Alcohol abstinence: Most important factor for improving survival 1
• Nutritional support:
  • Target 35-40 kcal/kg/day and 1.2-1.5 g/kg/day protein
  • Supplement B-complex vitamins and other micronutrients
  • Consider enteral feeding if oral intake inadequate 2
• Infection screening: Blood cultures, urine cultures, ascites fluid analysis 2

2. Pharmacological Treatment (For Severe Cases)

• Corticosteroids: Prednisolone 40 mg daily for 28 days for patients with mDF ≥32 1, 2
• Treatment response assessment:
  • Evaluate at day 7 using Lille model
  • If Lille score ≥0.45 (non-response), consider stopping steroids 2
• Alternative treatment:
  • Pentoxifylline (400 mg TID) if contraindications to steroids exist 1
  • Consider combination therapy with N-acetylcysteine + prednisolone, which has shown improved 1-month survival (8% mortality vs 24% with prednisolone alone) 1

3. Management of Complications

• Infections: Systematic microbiological screening before starting corticosteroids 2
• Renal protection: Avoid nephrotoxic drugs; monitor for hepatorenal syndrome 2
• Alcohol withdrawal syndrome: Manage with appropriate supportive care and medications 1

4. Rescue Therapy

• Liver transplantation: Consider for carefully selected patients with MELD >26 who fail medical therapy 1, 2
  • Outcomes similar to other transplanted patients with comparable MELD scores
  • Relapse rates post-transplantation appear similar to those with alcoholic cirrhosis 1

Prognosis and Follow-up

• Corticosteroid benefit is modest and limited to 28-day mortality
• 1-year mortality remains high (56% in the STOPAH trial) 1, 2
• Long-term outcomes depend primarily on maintaining abstinence from alcohol
  • 5-year survival: 80% with abstinence vs 50% with relapse 2

Important Considerations

• Early change in bilirubin level (ECBL) and Lille model are useful for predicting response to corticosteroids 1
• Combination of Lille and MELD scores provides optimal approach for evaluating short and medium-term mortality risk 2
• Anti-TNF-α agents (infliximab, etanercept) are not recommended due to higher mortality rates, mainly from increased infections 1

The treatment of alcoholic hepatitis remains challenging with limited options beyond corticosteroids. Ongoing research into new therapeutic targets focusing on inflammation, gut-liver axis, and liver regeneration may provide better treatment options in the future 3, 4.