What is the treatment for alcoholic hepatitis?

Treatment for Alcoholic Hepatitis

The cornerstone of alcoholic hepatitis treatment is complete alcohol abstinence, combined with nutritional support and corticosteroids for severe cases with poor prognostic indicators (MDF ≥32 or MELD >20). 1, 2

Assessment of Disease Severity

• Evaluate disease severity using validated scoring systems to guide treatment decisions:

  • Maddrey discriminant function (MDF) ≥32
  • MELD score >20
  • Glasgow alcoholic hepatitis score of 9
  • ABIC score category C 1

• Screen all patients for infections regardless of fever presence, with cultures of blood, urine, and ascites (if present) 1

First-Line Interventions

Alcohol Abstinence

• Complete abstinence from alcohol is essential as continued alcohol use leads to disease progression and worsens outcomes 1, 3
• Brief alcohol intervention during hospitalization reduces future alcohol consumption by approximately 41 g/week 4
• Extended alcohol counseling should be arranged after discharge to maintain abstinence 4

Nutritional Support

• Provide high-calorie, high-protein diet: 30-40 kcal/kg/day and 1.2-1.5 g/kg/day protein 1
• For severely ill patients, increase protein intake to 1.5 g/kg/day 4
• If three meals per day do not provide adequate nutrition, additional meals in the early morning and late at night can help restore nutritional balance 2
• Supplement with vitamins and minerals, particularly vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 2, 4

Treatment Based on Disease Severity

Non-Severe Alcoholic Hepatitis

• Supportive care with abstinence and nutritional therapy 5
• Monitor for complications of cirrhosis 3

Severe Alcoholic Hepatitis (MDF ≥32, MELD >20)

• Corticosteroid therapy with prednisolone 40 mg daily for 28 days (followed by discontinuation or 2-week taper) 1, 2
• Assess response to steroids at day 7 using:
  • Lille model (score <0.45 indicates good response with 85% 6-month survival)
  • Early Change in Bilirubin Level (ECBL) 1, 2
• If patient is a null responder (Lille score ≥0.56), consider discontinuing steroids to reduce risk of infection 2

Management of Complications

Infections

• Early screening for and treatment of infections is recommended 1, 6
• Use broad-spectrum antibiotics for confirmed or suspected infections 3
• Consider overlapping antibiotic therapy with any subsequent corticosteroid treatment 6

Acute Kidney Injury

• Avoid nephrotoxic drugs, including diuretics 1
• Use caution with iodinated contrast agents for imaging 1

Special Considerations

• Contraindications to steroid therapy include gastrointestinal bleeding, renal failure, pancreatitis, or uncontrolled infection 2
• For patients not responding to medical therapy, liver transplantation may be considered in highly selected cases, though this remains controversial and requires stable abstinence 5, 7
• Monitor for alcohol withdrawal and treat appropriately 4

Monitoring Response

• Evaluate response to treatment at day 7 using the Lille model or ECBL 1
• Continue monitoring for infections, which can develop after initial diagnosis and are associated with high mortality 1
• Long-term prognosis is primarily determined by continued abstinence from alcohol 5, 6