Initial Treatment for Alcoholic Hepatitis
The cornerstone of initial treatment for alcoholic hepatitis is complete alcohol abstinence, combined with nutritional support and, for severe cases (defined by Maddrey discriminant function >32 or MELD >20), corticosteroid therapy with prednisolone 40 mg daily for 28 days. 1
Assessment of Disease Severity
Disease severity must be evaluated using validated scoring systems to guide treatment decisions 1:
- Maddrey discriminant function (MDF) >32 predicts high 28-day mortality
- MELD score >20 predicts high 90-day mortality
- Glasgow alcoholic hepatitis score of 9 predicts high 28-day mortality
- ABIC score category C predicts high 28-day and 90-day mortality
All patients should be screened for infections regardless of fever presence, with cultures of blood, urine, and ascites (if present) 1
First-Line Interventions
1. Alcohol Abstinence
- Complete abstinence is essential as continued alcohol use leads to disease progression and worsens outcomes 1
- Brief alcohol intervention during hospitalization should be initiated, followed by extended counseling after discharge 2
2. Nutritional Support
- Provide high-calorie, high-protein diet: 30-40 kcal/kg/day and 1.2-1.5 g/kg/day protein 1
- For critically ill patients, increase protein intake to 1.5 g/kg/day 1, 2
- If unable to meet nutritional requirements with three meals daily, consider additional smaller meals or enteral feeding via tube if patient has anorexia or altered mental status 1
- Parenteral nutrition alone is inadequate 1
3. Vitamin and Mineral Supplementation
- Provide vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc supplements to correct nutritional deficiencies 1, 2
Treatment Based on Disease Severity
For Mild-Moderate Alcoholic Hepatitis (MDF <32, MELD <20)
- Focus on abstinence, nutritional support, and vitamin supplementation 1
- Monitor closely but specific medical interventions beyond supportive care are not required 1
For Severe Alcoholic Hepatitis (MDF ≥32, MELD >20)
- Corticosteroid therapy: Prednisolone 40 mg daily for 28 days (followed by discontinuation or 2-week taper) 1
- Assess response to steroids at day 7 using the Lille model or Early Change in Bilirubin Level (ECBL) 1:
- ECBL is defined as bilirubin level at day 7 lower than day 1
- Lille score <0.45 indicates good response (85% 6-month survival)
- Lille score >0.45 indicates poor response (25% 6-month survival)
For Patients with Contraindications to Steroids
- Contraindications include: gastrointestinal bleeding, renal failure, pancreatitis, uncontrolled infection, hepatitis B viral infection, tuberculosis 1
- Pentoxifylline 400 mg orally three times daily for 4 weeks is an alternative 1
- Pentoxifylline reduces risk of hepatorenal syndrome, which is a major cause of mortality 1
Special Considerations
- Avoid nephrotoxic drugs including diuretics, as acute kidney injury is an early manifestation of multi-organ failure 1
- Use caution with iodinated contrast agents for imaging as they increase risk of acute kidney injury 1
- Patients with severe alcoholic hepatitis and MELD score >26 with good insight into their alcohol use disorder and good social support should be referred for liver transplantation evaluation 1
- Systemic inflammatory response syndrome (SIRS) on admission indicates increased risk of multi-organ failure 1
Monitoring Response
- Evaluate response to treatment at day 7 using Lille model or ECBL 1
- Monitor for infections, which can develop after initial diagnosis and are associated with high mortality 1
- Assess nutritional status regularly and adjust supplementation as needed 1
The evidence strongly supports a structured approach to alcoholic hepatitis treatment, with disease severity guiding the intensity of interventions. While mild cases may improve with abstinence and nutritional support alone, severe cases require corticosteroid therapy unless contraindicated, in which case pentoxifylline is a reasonable alternative.