Contraindications of Steroids in Severe Alcoholic Hepatitis
Corticosteroid therapy in severe alcoholic hepatitis is contraindicated in patients with gastrointestinal bleeding, renal failure, pancreatitis, uncontrolled infection, hepatitis B viral infection, and tuberculosis. 1
Key Contraindications
The use of corticosteroids in severe alcoholic hepatitis (SAH) requires careful patient selection due to several important contraindications:
Active infections: Uncontrolled infections are a contraindication for steroid therapy 1. However, recent evidence suggests that after appropriate antibiotic therapy, corticosteroid treatment may not be precluded in patients with controlled infections 2.
Gastrointestinal bleeding: Patients with gastrointestinal hemorrhage may be less responsive to steroid treatment and have heightened risks of complications 2.
Renal failure/Hepatorenal syndrome: Patients with hepatorenal syndrome may have poorer response to steroids 2.
Pancreatitis: This is a contraindication for steroid use in SAH 1.
Hepatitis B viral infection: Active hepatitis B infection contraindicates steroid therapy 1.
Tuberculosis: Active or latent tuberculosis is a contraindication for steroid therapy 1.
Assessment Before Initiating Steroids
Before starting steroid therapy, a thorough evaluation is necessary:
Severity assessment: Use validated scoring systems such as Maddrey Discriminant Function (MDF ≥32) or MELD score (>20) to identify patients with severe disease who might benefit from steroids 1.
Infection screening: Systematic microbiological screening including blood, urine, and ascites cultures should be performed to rule out infections 1, 3.
Time for evaluation: Recent evidence suggests taking up to a week to systematically evaluate patients before initiating steroids 4.
Monitoring During Steroid Therapy
Early response assessment: Evaluate response to treatment at day 7 using the Lille model; a score ≥0.56 indicates a null responder and steroids should be discontinued 2, 1.
Infection surveillance: Vigilant monitoring for infections, particularly in the first month of treatment, is essential as infections occur more frequently in non-responders to steroids (42.5% vs 11.1% in responders) 4, 3.
Fungal infection risk: While corticosteroids do not increase the occurrence of bacterial infections, they may increase the risk of fungal infections 5.
Alternative Therapies When Steroids Are Contraindicated
Pentoxifylline: Consider pentoxifylline 400 mg three times daily for 28 days if steroids are contraindicated 2, 1.
Emerging therapies: For steroid-ineligible patients, therapies such as granulocyte colony stimulating factor, fecal microbiota transplantation, and plasma exchange show promise 6.
Important Considerations
Therapeutic window: Corticosteroids provide maximum survival benefit in patients with MELD scores between 25 and 39, with diminishing benefit at higher scores and no benefit with MELD >51 7.
Infection risk and response: Non-response to steroids (as determined by the Lille model) is the key factor in the development of infection after steroid initiation 3.
Steroid regimen: The most common regimen is prednisolone 40 mg daily for 28 days, followed by a two-week taper 2, 4.
Close follow-up: Regular monitoring and close outpatient follow-up are essential during and after steroid therapy 4.