What is the treatment for acute alcoholic hepatitis?

Treatment for Acute Alcoholic Hepatitis

Complete abstinence from alcohol is the cornerstone of treatment for acute alcoholic hepatitis, essential for improving survival, preventing disease progression, and potentially reversing liver damage. 1

Assessment of Disease Severity

First, evaluate the severity of alcoholic hepatitis using validated scoring systems:

• Maddrey Discriminant Function (MDF): Score ≥32 indicates severe disease
• MELD score: Score >20 indicates severe disease
• Glasgow alcoholic hepatitis score: Score ≥9 indicates need for aggressive treatment 1

Laboratory assessment should include:

• Liver function tests (AST:ALT ratio >2 suggests alcoholic etiology)
• Bilirubin, albumin, prothrombin time
• Complete blood count
• Renal function tests 1

Treatment Algorithm

1. Alcohol Abstinence Support

• Pharmacological support: Baclofen is recommended as a safe option for patients with liver disease 1
• Benzodiazepines for withdrawal symptoms should be used with caution, preferring short-acting agents 1

2. Pharmacological Treatment for Severe Disease

For patients with MDF ≥32 or MELD >20:

• First-line therapy: Prednisolone 40 mg daily for 28 days 1

  • Assess response at day 7 using the Lille model
  • If Lille score ≥0.56 (null responder), consider discontinuing steroids

• Contraindications to steroids include:

  • Gastrointestinal bleeding
  • Renal failure
  • Pancreatitis
  • Uncontrolled infection
  • Hepatitis B viral infection
  • Tuberculosis 1

• Alternative therapy if steroids are contraindicated:

  • Pentoxifylline 400 mg three times daily for 28 days 1
  • Note: The STOPAH study showed limited benefit of pentoxifylline on mortality 2

3. Nutritional Support

• Ensure adequate caloric intake (35-40 kcal/kg/day)
• Provide sufficient protein intake (1.2-1.5 g/kg/day)
• Supplement with vitamin B complex and folate
• Consider zinc supplementation to improve gut mucosal barrier integrity 1

4. Management of Complications

• Avoid nephrotoxic medications
• Use diuretics carefully
• Monitor for acute kidney injury
• Perform systematic microbiological screening (blood, urine, and ascites cultures) to rule out infections 1

5. Liver Transplantation

• Consider for selected patients with MELD >26 who fail medical therapy
• Requirements include:
  • Good insight into alcohol use disorder
  • Strong social support
  • Low risk of post-transplant alcohol use 1
• Early liver transplantation in selected non-responders to corticosteroids can significantly improve 6-month and long-term survival 3

Monitoring Treatment Response

• Assess response to corticosteroids at day 7 using:
  • Early Change in Bilirubin Level (ECBL)
  • Lille model (score ≤0.45 indicates response) 1, 3
• Regular liver function tests
• Imaging to assess hepatomegaly improvement
• Screening for hepatocellular carcinoma in cirrhotic patients 1

Important Considerations

• Long-term outcomes depend primarily on maintaining abstinence from alcohol, with 5-year survival rates of 80% with abstinence vs. 50% with relapse 1
• Corticosteroids plus N-acetylcysteine combination may improve short-term survival over corticosteroids alone 3
• Prognosis for non-responders to corticosteroids with Lille model >0.45 is poor, with only 23% survival at 6 months 3

Common Pitfalls to Avoid

1. Failing to assess disease severity properly before initiating treatment
2. Overlooking contraindications to steroid therapy
3. Not evaluating response to steroids at day 7
4. Inadequate nutritional support
5. Neglecting to screen for and treat infections
6. Continuing steroids in null responders (Lille score ≥0.56)