What is the recommended dose of steroid, specifically prednisolone, for the treatment of alcoholic hepatitis?

Steroid Dosing for Alcoholic Hepatitis

Prednisolone 40 mg daily for 28 days is the recommended standard dose for treating severe alcoholic hepatitis, as supported by multiple clinical guidelines. 1, 2

Patient Selection for Steroid Therapy

• Steroids are indicated for patients with severe alcoholic hepatitis, defined by:

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

• Patients with mild-moderate alcoholic hepatitis (mDF <32) should be monitored closely but typically don't require steroids, as they generally improve with abstinence and supportive care alone 1

Contraindications to Steroid Therapy

• Steroids should not be used in patients with: 1, 2
  • Active infection or sepsis
  • Gastrointestinal bleeding
  • Acute renal failure
  • Acute pancreatitis
  • Uncontrolled infection

Treatment Protocol

• The standard regimen is prednisolone 40 mg orally once daily for 28 days 1, 2
• Some protocols include a 2-week taper after the 28-day course 1, 2
• Methylprednisolone 32 mg daily has also been shown to be effective in clinical trials 3

Monitoring Response to Treatment

• Response to steroid therapy should be assessed after 7 days using: 1, 2

  • Early Change in Bilirubin Level (ECBL): defined as bilirubin level at day 7 being lower than on day 1 1
  • Lille model score: categorizes patients as:
    • Complete responders (score ≤0.16): 91.1% 28-day survival 1, 2
    • Partial responders (score 0.16-0.56): 79.4% 28-day survival 1, 2
    • Null responders (score ≥0.56): 53.3% 28-day survival 1, 2

• If the Lille score is ≥0.56 (null responder) or ECBL is not observed, steroids should be discontinued and alternative therapies considered 1

Alternative Therapy

• For patients with contraindications to steroids, pentoxifylline 400 mg three times daily for 28 days can be considered as an alternative 1, 2
• However, pentoxifylline is less effective than prednisolone, with studies showing lower response rates (74.5% vs 87.0% 1-month survival) 1, 4
• The STOPAH trial showed prednisolone was associated with a reduction in 28-day mortality that approached but did not reach statistical significance (14% vs 17%, p=0.06) 5

Treatment Algorithm

1. Assess severity of alcoholic hepatitis using mDF, MELD, or GAHS scores 1
2. For severe cases (mDF ≥32) without contraindications, start prednisolone 40 mg daily 1, 2
3. Assess response at day 7 using Lille model or ECBL 1, 2
4. If responsive (Lille <0.56), continue prednisolone for full 28-day course 1, 2
5. If non-responsive (Lille ≥0.56), discontinue steroids and consider alternative therapies 1
6. For patients with contraindications to steroids, use pentoxifylline 400 mg three times daily 1, 2

Important Considerations

• Alcohol abstinence remains the cornerstone of therapy for alcoholic hepatitis 1, 2
• Nutritional support is essential, as most patients with severe alcoholic hepatitis are malnourished 1
• Serious infections occur more frequently in patients treated with prednisolone (13% vs 7%, p=0.002) 5
• The 6-month survival rate is significantly better in patients with confirmed ECBL (82%) compared to those without (23%) 1