What is the recommended dose of prednisolone (corticosteroid) for treating alcoholic liver disease, specifically alcoholic hepatitis?

Recommended Dose of Prednisolone in Alcoholic Liver Disease

The recommended dose of prednisolone for treating severe alcoholic hepatitis is 40 mg daily for 28 days, with response assessment at day 7 using the Lille model to determine whether to continue or discontinue treatment. 1, 2

Diagnostic Criteria for Treatment Initiation

Treatment with prednisolone should be initiated in patients with severe alcoholic hepatitis, defined by:

• Maddrey Discriminant Function (MDF) ≥ 32
• MELD score > 20
• Glasgow alcoholic hepatitis score ≥ 9 2

Treatment Protocol

1. Dosage and Duration:

   • Prednisolone 40 mg orally once daily for 28 days 1, 2
   • Alternatively, methylprednisolone 32 mg daily can be used 1

2. Response Assessment:

   • Evaluate response at day 7 using the Lille model
   • If Lille score ≥ 0.45: Consider stopping treatment
   • If Lille score ≥ 0.56 ("null responders"): Definitely stop treatment 1, 2

3. Discontinuation:

   • After completing the 28-day course, prednisolone can either:
     • Be stopped abruptly, or
     • Tapered gradually over 3 weeks 1

Contraindications and Precautions

Corticosteroid therapy is contraindicated in patients with:

• Uncontrolled infections
• Gastrointestinal bleeding
• Renal failure
• Pancreatitis
• Hepatitis B viral infection
• Tuberculosis 2

Efficacy and Limitations

The STOPAH trial (2015) showed that prednisolone was associated with a reduction in 28-day mortality that approached but did not reach statistical significance (odds ratio 0.72,95% CI 0.52-1.01, P=0.06) 3. Importantly, prednisolone provides no survival benefit beyond one month of therapy 1.

The main concerns with prednisolone therapy include:

• Increased risk of serious infections (13% vs 7% in patients not receiving prednisolone, P=0.002) 3
• Risk of gastrointestinal bleeding 1

Alternative Treatments

For patients with contraindications to prednisolone:

• Pentoxifylline 400 mg three times daily for 28 days may be considered, though evidence suggests it does not improve survival compared to placebo 2, 3
• The combination of prednisolone and pentoxifylline does not provide additional survival benefit over prednisolone alone 4, 5

Monitoring During Treatment

• Regular assessment for infections (blood, urine, and ascites cultures)
• Monitoring of renal function
• Regular liver function tests
• Assessment of response using the Lille model at day 7 2

Important Caveats

1. Early identification of non-responders is crucial to limit unnecessary exposure to corticosteroids in patients unlikely to benefit 1

2. Complete abstinence from alcohol is essential for improving survival and preventing disease progression 2

3. Nutritional support with adequate caloric intake (35-40 kcal/kg/day) and protein intake (1.2-1.5 g/kg/day) is an important adjunct to pharmacological therapy 2

4. Consider liver transplantation for selected patients with MELD > 26 who fail medical therapy 2