Liquid Prednisolone for Alcoholic Hepatitis
Liquid prednisolone is an appropriate and recommended treatment option for severe alcoholic hepatitis with a Maddrey Discriminant Function (mDF) score ≥32 or Glasgow Alcoholic Hepatitis Score (GAHS) ≥9.
Assessment of Disease Severity
Before initiating treatment, severity assessment is crucial:
- Use validated scoring systems:
- Maddrey Discriminant Function (mDF) ≥32
- Glasgow Alcoholic Hepatitis Score (GAHS) ≥9
- MELD score >20
These scores determine the need for corticosteroid therapy 1.
Corticosteroid Treatment Protocol
For patients with severe alcoholic hepatitis:
- Dosage: Prednisolone 40 mg daily for 28 days 1
- Administration: Liquid prednisolone is an acceptable formulation and may be preferred in patients with swallowing difficulties or requiring nasogastric administration
- Treatment duration: 28 days, with assessment of response at day 7 using the Lille model 1
- Response assessment:
- If Lille score <0.45: Continue treatment for full 28 days
- If Lille score ≥0.45 (especially ≥0.56): Consider stopping treatment 1
Contraindications to Corticosteroids
Avoid prednisolone in patients with:
- Active infection
- Gastrointestinal bleeding
- Renal failure
- Pancreatitis
- Hepatitis B viral infection
- Tuberculosis 1
In these cases, pentoxifylline 400 mg three times daily for 28 days may be considered as an alternative 1.
Monitoring During Treatment
- Assess treatment response at day 7 using Lille model
- Monitor for infections (prednisolone increases risk of serious infections) 2
- Screen for bacterial infections before and during treatment
- Monitor liver function tests regularly
- Assess nutritional status and ensure adequate caloric intake (35-40 kcal/kg/day) 1
Infection Risk with Prednisolone
Recent evidence shows prednisolone increases susceptibility to infection:
- Serious infections are more frequent in patients treated with prednisolone (OR 1.27,95% CI 1.27-2.92) 2
- Post-treatment infections are higher with prednisolone (10% vs 6% in non-prednisolone group) 2
- Infections account for significant mortality in prednisolone-treated patients 2
Emerging Alternative Treatments
Recent research suggests fecal microbiota transplantation (FMT) may be superior to prednisolone:
- A 2023 randomized trial showed improved 90-day survival with FMT compared to prednisolone (75% vs 56.6%, p=0.044) 3
- FMT was associated with fewer infection-related deaths (3.6% vs 19.3%, p=0.01) 3
However, this is a single study and not yet incorporated into guidelines.
Conclusion
Liquid prednisolone at 40 mg daily for 28 days is an appropriate treatment for severe alcoholic hepatitis when the mDF score is ≥32 or GAHS is ≥9. Treatment response should be assessed at day 7, and prednisolone should be discontinued if the Lille score is ≥0.56. Careful monitoring for infections is essential as they represent a significant risk with prednisolone therapy.