What is the recommended treatment for alcoholic hepatitis?

Treatment of Alcoholic Hepatitis

Complete abstinence from alcohol is the cornerstone of treatment for alcoholic hepatitis, with additional therapy determined by disease severity using validated scoring systems such as Maddrey Discriminant Function (mDF ≥32) or MELD score (>20). 1

Initial Assessment and Stratification

• Disease severity assessment using:

  • Maddrey Discriminant Function (mDF): ≥32 indicates severe disease
  • MELD score: >20 indicates severe disease
  • Glasgow alcoholic hepatitis score: ≥9 indicates need for aggressive treatment

• Systematic screening for infections (blood, urine, and ascites cultures) before initiating immunosuppressive therapy 1

Treatment Algorithm

First-line Treatment for All Patients

1. Complete alcohol abstinence - essential for all patients regardless of disease severity 1, 2

   • Abstinence counseling should be provided
   • In compensated cirrhosis, 5-year survival is 90% with abstinence vs <70% with continued drinking 1

2. Nutritional support 1

   • Ensure adequate protein intake (1.2-1.5 g/kg/day)
   • Provide sufficient calories (35-40 kcal/kg/day)
   • Supplement with vitamin B complex and folic acid

Treatment Based on Disease Severity

Mild Alcoholic Hepatitis

• Supportive care and abstinence are sufficient 3, 4
• Monitor for progression of disease

Severe Alcoholic Hepatitis (mDF ≥32 or MELD >20)

1. Corticosteroids 1, 4

   • Prednisolone 40 mg daily or methylprednisolone 32 mg daily for 28 days
   • Assess response at day 7 using Lille model:
     • If Lille score <0.56: Continue full 28-day course
     • If Lille score ≥0.56 (null responder): Consider discontinuing steroids

2. Contraindications to steroids include 1:

   • Gastrointestinal bleeding
   • Renal failure
   • Pancreatitis
   • Uncontrolled infection
   • Hepatitis B viral infection
   • Tuberculosis

3. Alternative treatment if steroids contraindicated 1:

   • Pentoxifylline 400 mg three times daily for 28 days
   • Note: The STOPAH study showed limited benefit of pentoxifylline 5

Management of Complications

1. Avoid nephrotoxic medications 1

   • Acute kidney injury is an early manifestation of multi-organ failure
   • Use caution with diuretics and iodinated contrast agents

2. Monitor for infections 1

   • Higher infection risk in patients treated with prednisolone (13% vs 7% in controls)
   • Regular screening for infections is recommended

Liver Transplantation

Consider liver transplantation for 1, 3:

• Patients with MELD >26 who fail medical therapy
• Carefully selected patients with:
  • Good insight into their alcohol use disorder
  • Strong social support
  • Failure to respond to medical therapy

Recent evidence suggests early liver transplantation in carefully selected patients can provide significant survival benefit with 6-month survival rates of 77-100% 3

Emerging Therapies

Recent research is investigating 6:

• Anti-inflammatory agents
• Modifications of the gut-liver axis
• Fecal microbiota transplantation (FMT) - showing promise for improved 90-day survival compared to prednisolone 1
• Epigenetic modulation
• Antioxidants
• Drugs targeting liver regeneration

Important Considerations

• Steatosis is reversible with abstinence, but alcoholic hepatitis may persist and progress to cirrhosis even with abstinence 2
• Long-term outcomes depend primarily on maintaining abstinence, with 5-year survival rates of 80% with abstinence vs 50% with relapse 1
• A multidisciplinary approach involving substance abuse specialists, hepatologists, dietitians, and other specialists is recommended for comprehensive care 4