What is the recommended treatment duration for alcoholic hepatitis?

Treatment Duration for Alcoholic Hepatitis

The recommended treatment duration for alcoholic hepatitis is 28 days of prednisolone 40 mg daily for severe cases, followed by lifelong complete alcohol abstinence, which is the cornerstone of therapy. 1

Diagnosis and Severity Assessment

Before initiating treatment, assess disease severity using validated scoring systems:

• Maddrey Discriminant Function (mDF) ≥32
• MELD score >20
• Glasgow alcoholic hepatitis score ≥9
• Presence of hepatic encephalopathy

These scores help determine which patients require pharmacological intervention beyond abstinence 1.

Treatment Algorithm

Step 1: Abstinence

• Complete alcohol abstinence is essential for all patients with alcoholic hepatitis
• After an episode of alcoholic hepatitis, there is no safe amount of alcohol consumption that can be recommended 2
• 5-year survival rates: 80% with abstinence vs. 50% with continued drinking 1

Step 2: Pharmacological Treatment for Severe Cases

• Prednisolone 40 mg daily for 28 days for patients with:

  • mDF ≥32
  • MELD >20
  • Hepatic encephalopathy 2, 1

• Alternative if steroids contraindicated:

  • Pentoxifylline 400 mg three times daily for 28 days 2

Step 3: Response Assessment

• Evaluate response to steroids at day 7 using:

  • Early Change in Bilirubin Level (ECBL): bilirubin at day 7 should be lower than day 1
  • Lille model score: <0.45 indicates response 2, 1

• If no response (Lille score ≥0.56 or no ECBL):

  • Consider discontinuing steroids
  • Evaluate for liver transplantation or alternative therapies 2

Evidence Quality and Considerations

The 28-day treatment duration for prednisolone is well-established across multiple guidelines and clinical trials 2, 1. This duration has been consistently used in major studies including the STOPAH trial, which evaluated prednisolone and pentoxifylline in severe alcoholic hepatitis 3.

It's important to note that while steroids improve short-term (28-day) survival, they have not consistently shown benefit for long-term outcomes. The STOPAH trial demonstrated that prednisolone reduced 28-day mortality (14% vs 17% in placebo), but this benefit did not persist at 90 days or 1 year 3.

Common Pitfalls and Caveats

1. Infection risk: Steroids increase infection risk (13% with prednisolone vs. 7% without) 3. Perform systematic microbiological screening before starting corticosteroids.

2. Contraindications to steroids:

   • Gastrointestinal bleeding
   • Renal failure
   • Pancreatitis
   • Uncontrolled infection 2

3. Non-responders: Continuing steroids beyond 7 days in non-responders (Lille score ≥0.56) may increase mortality due to infections 2.

4. Nutritional support: Provide adequate nutrition with protein intake of 1.2-1.5 g/kg/day and caloric intake of 35-40 kcal/kg/day 1.

5. Emerging therapies: Recent research suggests fecal microbiota transplantation (FMT) may improve 90-day survival compared to prednisolone (75% vs 56.6%) with fewer infections 4, but this is not yet incorporated into guidelines.

Remember that while the standard pharmacological treatment duration is 28 days, the need for complete alcohol abstinence is lifelong, as this is the most important factor for long-term survival.