What is the recommended dosage of steroids, such as prednisolone (corticosteroid), for patients with a positive Maddrey's score indicating severe alcoholic hepatitis?

Steroid Dosage for Patients with Positive Maddrey's Score in Alcoholic Hepatitis

For patients with severe alcoholic hepatitis defined by a Maddrey's Discriminant Function (mDF) score ≥32, prednisolone 40 mg daily for 28 days is the recommended standard treatment regimen. 1, 2

Diagnostic Criteria for Severe Alcoholic Hepatitis

• Severe alcoholic hepatitis requiring steroid therapy is defined by:

  • Maddrey's Discriminant Function (mDF) score ≥32 2, 1
  • MELD score >21 1
  • Glasgow Alcoholic Hepatitis Score (GAHS) ≥9 1
  • Presence of hepatic encephalopathy 1

• Patients with mild alcoholic hepatitis (mDF <32) generally improve with abstinence and supportive care alone without steroid therapy 1

Standard Steroid Treatment Protocol

• Prednisolone 40 mg orally once daily for 28 days is the standard recommended regimen 2, 1
• After completing the 28-day course, prednisolone can be either:
  • Discontinued abruptly, or
  • Tapered over 2 weeks 1
• The type of corticosteroid used (prednisolone, prednisone, or methylprednisolone) does not significantly affect survival outcomes 3

Monitoring Response to Steroid Treatment

• Response to steroid therapy should be assessed at day 7 using:

  • The Lille model score 2, 1
  • Early Change in Bilirubin Level (ECBL) 2

• Based on the Lille model score at day 7, patients are categorized as:

  • Complete responders (score ≤0.16): 91.1% 28-day survival rate 2, 1
  • Partial responders (score 0.16-0.56): 79.4% 28-day survival rate 2, 1
  • Null responders (score ≥0.56): 53.3% 28-day survival rate 2, 1

• If the Lille score is ≥0.56 (null responder), steroids should be discontinued and alternative therapies considered 2

Therapeutic Window for Steroid Treatment

• Steroids are most effective in patients with MELD scores between 25-39, providing a 21-30% survival benefit 3
• Steroid benefit is observed in patients with MELD scores between 21-51 3
• No survival benefit is seen in patients with MELD scores >51 3

Contraindications to Steroid Therapy

• Active infection or sepsis 1
• Gastrointestinal bleeding 1
• Acute renal failure 1
• Acute pancreatitis 1

Alternative Treatment for Contraindicated Cases

• For patients with contraindications to steroids, pentoxifylline 400 mg three times daily for 28 days is recommended as an alternative 2, 1
• Pentoxifylline is particularly useful in patients with early renal failure or at high risk of hepatorenal syndrome 2
• However, pentoxifylline is less effective than prednisolone for improving survival 1, 4

Treatment Algorithm

1. Assess severity using mDF score, MELD, or GAHS
2. If mDF ≥32 and no contraindications: Start prednisolone 40 mg daily 2
3. Assess response at day 7 using Lille model 2, 1
4. If Lille score <0.56: Continue prednisolone for full 28-day course 2, 1
5. If Lille score ≥0.56: Discontinue steroids and consider alternative approaches 2
6. If contraindications to steroids exist: Use pentoxifylline 400 mg three times daily 2, 1

Important Caveats

• Combination therapy with prednisolone plus pentoxifylline does not improve survival compared to prednisolone alone 5, 6, 4, 7
• Long-term outcomes depend primarily on achieving alcohol abstinence 1
• Nutritional support is essential alongside pharmacological treatment 2
• Infection risk is higher in patients receiving prednisolone (13%) compared to those not receiving prednisolone (7%) 4