What is the management of alcohol-induced hepatitis?

Management of Alcohol-Induced Hepatitis

For patients with severe alcoholic hepatitis (defined by Maddrey Discriminant Function ≥32 or MELD >20), prednisolone 40 mg daily for 28 days is the recommended first-line treatment, with response assessment at day 7 using the Lille model. 1, 2, 3

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, and 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 4, 1
  • MELD score >20 predicts high 90-day mortality 4, 2
  • Glasgow Alcoholic Hepatitis Score (GAHS) ≥9 or ABIC score category C also predict high mortality 4, 3
• Systematic screening for infections (blood cultures, urine cultures, and ascites fluid culture if present) is mandatory before initiating treatment 1, 2

Initial Management

• Complete abstinence from alcohol is essential for all patients 4, 1, 2
• Hospitalize patients with severe alcoholic hepatitis or those with inadequate social/medical support 2
• Provide nutritional support with 1-1.5 g protein and 30-40 kcal/kg body weight daily 1, 2
• Consider enteral feeding via nasogastric tube if patient cannot eat due to anorexia or altered mental status 2
• Avoid nephrotoxic drugs including diuretics, as acute kidney injury is an early manifestation of multi-organ failure 2

Pharmacological Management for Severe Alcoholic Hepatitis

• For severe alcoholic hepatitis (MDF ≥32 or MELD >20) without contraindications, administer prednisolone 40 mg daily or methylprednisolone 32 mg daily for 28 days 1, 2, 3
• Contraindications to steroid therapy include active infection or sepsis, gastrointestinal bleeding, acute renal failure, and acute pancreatitis 3
• Assess response to corticosteroid therapy after 7 days using the Lille model:
  • Complete responders (score ≤0.16): continue treatment 3
  • Partial responders (score 0.16-0.56): continue treatment 3
  • Null responders (score ≥0.56): consider discontinuing steroids due to poor prognosis 2, 3
• Alternative therapy for patients with contraindications to corticosteroids:
  • N-acetylcysteine combined with corticosteroids may improve short-term survival 1, 3
  • Pentoxifylline 400 mg three times daily for 28 days can be considered, although it is less effective than steroids 3

Management for Mild to Moderate Alcoholic Hepatitis

• For patients with mild to moderate disease (MDF <32, MELD <20), focus on abstinence counseling and nutritional support 2, 3
• Prescribe high protein diet supplemented with B vitamins and folic acid 2
• Even in these "less severe" cases, recognize that mortality remains significant (10% at 6 months, 20% at 1 year) 2

Monitoring and Follow-up

• Combining the Lille and MELD scores provides optimal prediction of short and medium-term mortality risk 1, 2
• Monitor closely for infections during treatment, especially in patients on corticosteroids 1, 2
• Long-term outcomes depend primarily on maintaining abstinence:
  • 5-year survival rates of approximately 80% if abstinence is maintained
  • Survival drops to approximately 50% with alcohol relapse 1, 2

Liver Transplantation Consideration

• Refer patients with severe alcoholic hepatitis (particularly MELD >26) with good insight into their alcohol use disorder and strong social support for liver transplantation evaluation 2
• The 90-day mortality rate is very high in these patients without transplantation 2

Common Pitfalls and Caveats

• The immune response is impaired in patients with alcoholic hepatitis, placing them at high risk for bacterial and fungal infections 4, 1
• Development of multi-organ failure is associated with very high mortality 1
• Corticosteroid therapy improves short-term (28-day) survival but shows no significant benefit at 3 months and beyond 1, 3
• Most patients with alcoholic hepatitis already have underlying cirrhosis at diagnosis 2
• Do not delay assessment of disease severity - early stratification is crucial for timely intervention 2