What is the management of alcohol-induced hepatitis?

Management of Alcohol-Induced Hepatitis

The cornerstone of treatment for alcohol-induced hepatitis is complete abstinence from alcohol, with corticosteroid therapy (prednisolone 40 mg daily or methylprednisolone 32 mg daily for 28 days) recommended for severe cases with Maddrey discriminant function (MDF) >32 or MELD score >20. 1

Diagnosis and Assessment

• Diagnosis is based on clinical and laboratory parameters including:

  • Onset of jaundice within 8 weeks of last drinking period
  • Heavy drinking (>40 g/day) for more than 6 months
  • Serum bilirubin >3.0 mg/dL
  • Serum AST >50 IU/L but <400 IU/L
  • Serum AST/ALT ratio >1.5 1

• Severity assessment should be performed using validated scoring systems:

  • 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 1, 2

• Systematic screening for infections is mandatory before initiating treatment:

  • Blood cultures
  • Urine cultures
  • Ascites fluid culture (if present) 1

Treatment Algorithm

For All Patients

• Complete abstinence from alcohol is essential 1
• Nutritional support with 1-1.5 g protein and 30-40 kcal/kg body weight daily 1
• Consider enteral tube feeding if patient cannot maintain adequate oral intake 1, 3
• Avoid nephrotoxic drugs including diuretics 1

For Severe Alcoholic Hepatitis (MDF >32 or MELD >20)

1. First-line treatment: Corticosteroids (prednisolone 40 mg/day or methylprednisolone 32 mg/day) for 28 days 1, 2

   • Contraindications to corticosteroids:
     • Active infection or sepsis
     • Gastrointestinal bleeding
     • Hepatitis B infection
     • Tuberculosis
     • Other serious infectious diseases 1, 2

2. Assess response at day 7 using Lille score:

   • If Lille score <0.45: Continue corticosteroids for full 28-day course 1, 3
   • If Lille score ≥0.56: Discontinue corticosteroids (null responders) 1, 3

3. Alternative therapy for patients with contraindications to corticosteroids:

   • N-acetylcysteine combined with corticosteroids may improve short-term survival at 1 and 3 months (weak recommendation) 1, 3
   • Pentoxifylline is no longer recommended due to lack of efficacy in recent studies 1

4. Consider fast-track liver transplantation for patients not responding to medical therapy who meet strict selection criteria 1

Monitoring and Follow-up

• Combining the Lille and MELD scores provides optimal prediction of short and medium-term mortality risk 1
• Perform extensive bacteriological examination and investigate for fungal infection if symptoms or signs of infection develop during treatment 1, 3
• Long-term outcomes depend primarily on maintaining abstinence:
  • Medical treatment responders with maintained abstinence have 5-year survival rates of approximately 80%
  • Survival drops to approximately 50% with alcohol relapse 1

Common Pitfalls and Caveats

• The immune response is impaired in patients with alcoholic hepatitis, placing them at high risk for bacterial and fungal infections 1
• Corticosteroid therapy improves short-term (28-day) survival but shows no significant benefit at 3 months and beyond 1
• Development of multi-organ failure, usually due to infections after initial diagnosis, is associated with very high mortality 1
• Acute kidney injury is an early manifestation of multi-organ failure; nephrotoxic drugs should be avoided 1
• Addiction treatment must be systematically offered after an episode of alcoholic hepatitis to improve long-term outcomes 1