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

• Evaluate severity using validated scoring systems:

  • Maddrey Discriminant Function (MDF): ≥32 indicates severe disease
  • MELD score: >20 indicates severe disease
  • Glasgow alcoholic hepatitis 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

First-Line Treatment

1. For severe alcoholic hepatitis (MDF ≥32 or MELD >20):

   • Prednisolone 40 mg daily for 28 days 1, 2
   • Consider combination of corticosteroids plus N-acetylcysteine which improves short-term survival over corticosteroids alone 2
   • Assess response at day 7 using Lille model (responder if score ≤0.45) 1, 2
   • Discontinue steroids if Lille score ≥0.56 (null responder) 1

2. Contraindications to steroid treatment:

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

3. If steroids are contraindicated:

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

Pharmacological Support for Abstinence

• Baclofen is safe in patients with liver disease for maintaining abstinence 1
• For alcohol withdrawal:
  • Use benzodiazepines with caution, preferring short-acting agents
  • Provide thiamine supplementation (100-300 mg/day) to prevent Wernicke encephalopathy 1

Monitoring and Complications Management

• Systematic microbiological screening (blood, urine, ascites cultures) to rule out infections 1
• Avoid nephrotoxic medications and use diuretics carefully 1
• Regular liver function tests and imaging to assess improvement 1

Salvage Therapy

• For non-responders to corticosteroids (Lille model >0.45):
  • Prognosis is poor with only 23% survival at 6 months 2
  • Consider early liver transplantation in highly selected patients with MELD >26 who:
    • Have good insight into alcohol use disorder
    • Have strong social support
    • Show low risk of post-transplant alcohol use 1, 2

Long-term Management

• Long-term outcomes depend primarily on maintaining abstinence from alcohol
• 5-year survival rates: 80% with abstinence vs. 50% with relapse 1
• Regular screening for hepatocellular carcinoma in cirrhotic patients 1

Clinical Pitfalls to Avoid

• Failing to assess disease severity with validated scoring systems
• Initiating corticosteroids in patients with contraindications
• Not evaluating response to corticosteroids at day 7
• Inadequate nutritional support
• Neglecting to screen for and treat infections
• Not addressing alcohol use disorder as part of comprehensive treatment

The treatment approach should be guided by disease severity, with corticosteroids being the mainstay for severe disease while ensuring abstinence and nutritional support for all patients. Early liver transplantation may be considered for selected non-responders to medical therapy, though this remains controversial and requires careful patient selection 1, 3, 2.