What is the dose of steroids (corticosteroids) to be given to a patient with a Maddrey's score of 171?

Steroid Dosing for Alcoholic Hepatitis with Maddrey Score of 171

For a patient with a Maddrey score of 171, prednisolone 40 mg daily for 28 days is the recommended steroid dosing regimen. 1

Treatment Algorithm for Severe Alcoholic Hepatitis

Initial Assessment

• Maddrey score of 171 indicates very severe alcoholic hepatitis (well above the threshold of ≥32 that defines severe disease)
• Perform systematic screening for infection before starting steroids
• Evaluate nutritional status and ensure adequate caloric intake (35-40 kcal/kg/day)

Steroid Therapy

• First-line treatment: Prednisolone 40 mg daily for 28 days 1
• Alternative option: Methylprednisolone 32 mg daily for 28 days 1

Monitoring Response

• Calculate Lille score at day 7 of treatment to assess response
• If Lille score <0.45: Continue prednisolone for the full 28-day course
• If Lille score ≥0.56 (null responder): Stop prednisolone immediately 1
• If Lille score between 0.45-0.56: Consider stopping steroids based on individual assessment 1

Steroid Discontinuation

• After completing the 28-day course, prednisolone can be either:
  • Stopped abruptly, or
  • Tapered over a period of three weeks 1

Important Considerations

Contraindications to Steroids

If steroids are contraindicated (active infection, gastrointestinal bleeding, hepatorenal syndrome), consider pentoxifylline 400 mg three times daily for 28 days as an alternative 1.

Nutritional Support

• Ensure daily target of 35-40 kcal/kg body weight
• Prefer oral route as first-line nutritional intervention
• Supplement with B-complex vitamins 1

Infection Risk

• The very high Maddrey score (171) indicates extremely severe disease with high mortality risk
• Patients with such high scores are at increased risk for infections while on steroids
• Systematic evaluation and treatment of infections is essential before starting steroids 1

Evidence Strength and Limitations

The recommended dose of 40 mg prednisolone daily is consistently supported across multiple guidelines 1. This dosing has been validated in several randomized controlled trials, including the large STOPAH trial 1.

Recent research suggests that steroid benefit is most pronounced in patients with MELD scores between 25-39, with diminishing returns at very high severity scores 2. With a Maddrey score of 171, this patient is at the extreme end of disease severity, where the mortality benefit of steroids may be less pronounced, but treatment should still be initiated given the lack of better alternatives.

Despite the high Maddrey score, the standard dosing regimen remains 40 mg of prednisolone daily, as there is no evidence supporting higher doses even in extremely severe cases.