Maddrey Score Cut-off for Prednisone in Alcoholic Hepatitis
The Maddrey Discriminant Function (mDF) score cut-off for initiating prednisone therapy in alcoholic hepatitis is ≥32, which defines severe alcoholic hepatitis requiring corticosteroid treatment. 1, 2
Assessment of Disease Severity
- Severe alcoholic hepatitis is defined by a Maddrey Discriminant Function (mDF) score ≥32, MELD score >20-21, Glasgow Alcoholic Hepatitis Score (GAHS) ≥9, or presence of hepatic encephalopathy 1, 2
- Patients with mDF <32 were previously considered to have "non-severe" alcoholic hepatitis, but this terminology is now discouraged as these patients still have approximately 20% 1-year mortality 1
- Current terminology recommends using "symptomatic alcoholic hepatitis with moderate severity" for patients with mDF <32 and "symptomatic alcoholic hepatitis with severe severity" for those with mDF ≥32 1
Treatment Recommendations Based on Maddrey Score
- Patients with mDF <32 (moderate alcoholic hepatitis) should be monitored closely but typically do not require nor benefit from specific medical interventions beyond nutritional support and alcohol abstinence 1, 2
- Patients with mDF ≥32 (severe alcoholic hepatitis) and lacking contraindications to steroid use should receive prednisolone 40 mg/day for 28 days, typically followed by discontinuation or a 2-week taper 1, 2
- The therapeutic window for maximum benefit from corticosteroids is in patients with MELD scores between 25 and 39, with a 21-30% survival benefit 3
Monitoring Response to Treatment
- Response to corticosteroid therapy should be assessed at day 7 using the Lille model 1, 2
- A Lille score <0.45 indicates good response (responders) with 70-85% 6-month survival 1, 2
- A Lille score ≥0.45 indicates poor response (non-responders) with 20-30% 6-month survival 1
- For patients with Lille score ≥0.56 (null responders), corticosteroid therapy should be discontinued as it provides no benefit over placebo 1
- Early Change in Bilirubin Level (ECBL) at day 7 is another marker of response - patients with confirmed ECBL have 82% 6-month survival versus only 23% in those without ECBL 1, 4
Contraindications to Corticosteroid Therapy
- Corticosteroids are contraindicated in patients with 2:
- Active infection or sepsis
- Gastrointestinal bleeding
- Acute renal failure
- Acute pancreatitis
Alternative Therapies
- Pentoxifylline (400 mg orally three times daily for 4 weeks) can be considered for patients with severe alcoholic hepatitis (mDF >32) who have contraindications to steroid therapy 1, 2
- However, pentoxifylline is less effective than prednisolone for improving survival but may reduce the risk of hepatorenal syndrome 1, 5
Common Pitfalls and Caveats
- Infection screening should be performed in all patients with alcoholic hepatitis before initiating corticosteroid therapy, as infection is a contraindication 1, 6
- Long-term outcomes depend primarily on achieving alcohol abstinence, which should be strongly recommended to all patients 2, 6
- Nutritional support is crucial in alcoholic hepatitis management, with recommendation for high-calorie (30-40 kcal/kg/day) and high-protein (1.2-1.5 g/kg/day) diet 6
- Corticosteroid benefit is lost in patients with extremely severe disease (MELD >51), highlighting the importance of timely intervention 3