Why are steroids used for a patient with a Discerning Function (DF) score indicating significant liver dysfunction?

Steroids for Alcoholic Hepatitis with DF Score ≥32

Corticosteroids (prednisolone 40 mg daily for 28 days) are recommended for patients with severe alcoholic hepatitis defined by a Maddrey Discriminant Function (DF) score ≥32 because they significantly reduce short-term mortality by approximately 30%. 1

Rationale for Using Steroids in Severe Alcoholic Hepatitis

• Corticosteroids act by reducing the transcription of pro-inflammatory cytokines such as TNF-α, which play a pivotal role in the pathophysiology of alcoholic hepatitis 1
• Meta-analyses of clinical trials have demonstrated a significant increase in short-term survival among steroid-treated patients compared to controls (84.6% vs 65%), translating to a number needed to treat of 5 1
• The therapeutic window for steroid treatment is most effective with MELD scores between 25 and 39, where the maximum survival benefit (21-30%) is observed 2

Patient Selection Criteria

• Steroids are indicated for patients with:

  • DF score ≥32 (primary criterion) 1
  • MELD score >20 (alternative criterion) 1
  • Presence of hepatic encephalopathy (additional indicator) 1

• Contraindications to steroid therapy include:

  • Uncontrolled infections 1
  • Acute kidney injury with serum creatinine >2.5 mg/dL 1
  • Gastrointestinal bleeding 1
  • Acute pancreatitis 1

Treatment Protocol

• Prednisolone 40 mg daily for 28 days is the recommended regimen (preferred over prednisone due to impaired conversion of prednisone to prednisolone in liver disease) 1, 3

• Response to treatment should be assessed at day 7 using the Lille model:

  • Lille score <0.45 indicates good response - continue prednisolone for the full 28 days 1
  • Lille score >0.45 indicates poor response - consider discontinuation of steroids 1
  • Lille score >0.56 indicates null response - steroids should be stopped 1

• Early change in bilirubin level (ECBL) at day 7 is another indicator of response:

  • Decreased bilirubin at day 7 compared to day 1 predicts better 6-month survival (82% vs 23%) 1

Cautions and Monitoring

• Patients with hypoalbuminemia may require dose reduction due to decreased protein binding and delayed clearance of prednisolone 3
• Regular monitoring for infections is crucial as they occur in 12-26% of patients at admission and up to 50% during steroid treatment 1
• Liver function tests should be monitored every two weeks during treatment 4
• There may be a ceiling effect where steroids are harmful rather than beneficial at very high DF scores (>54) 1
• For patients with MELD >51, steroids show no survival benefit 2

Alternative Therapy

• For patients with contraindications to steroids, pentoxifylline (400 mg orally three times daily for 4 weeks) can be considered 1, 5
• Pentoxifylline works by inhibiting TNF-α production and has been shown to reduce the incidence of hepatorenal syndrome 1, 5
• However, pentoxifylline is generally less effective than corticosteroids for improving short-term survival 5

Supportive Care

• Nutritional support is essential as most patients with severe alcoholic hepatitis are malnourished 1
• Complete alcohol abstinence must be emphasized as it is the most important factor for long-term survival 1, 5
• Vitamin and mineral supplementation should be provided to address nutritional deficiencies 1

Remember that while steroids improve 30-day survival in patients with severe alcoholic hepatitis (DF ≥32), their benefit is limited to specific severity ranges, and careful patient selection with close monitoring is essential for optimal outcomes.