What is the treatment for alcoholic hepatitis?

Treatment of Alcoholic Hepatitis

Alcohol abstinence is the absolute cornerstone of treatment for all patients with alcoholic hepatitis, and for severe disease (mDF ≥32 or MELD >20), prednisolone 40 mg daily for 28 days should be initiated unless contraindications exist. 1, 2

Initial Assessment and Severity Stratification

Before initiating treatment, disease severity must be determined using validated scoring systems:

• Modified Discriminant Function (mDF) ≥32 indicates severe disease requiring pharmacologic intervention 1, 2
• MELD score >20-21 or GAHS ≥9 are alternative thresholds for defining severe disease 1, 2
• Presence of hepatic encephalopathy alone warrants consideration of treatment regardless of other scores 1

All patients should be screened for infections at presentation with blood, urine, and ascitic fluid cultures (if ascites present), even without fever, as infection significantly worsens prognosis 2

Universal Treatment Components

Alcohol Abstinence

Complete and permanent abstinence from alcohol is mandatory - there is no safe amount of alcohol consumption after an episode of alcoholic hepatitis, as the disease can persist or redevelop with any continued drinking 1

• Naltrexone or acamprosate may be used in combination with counseling to reduce relapse risk in patients who achieve abstinence 1
• Baclofen has shown benefit in maintaining abstinence in patients with cirrhosis 1

Nutritional Support

Aggressive nutritional therapy is essential as most patients with severe alcoholic hepatitis are malnourished, which independently worsens outcomes 1

• Caloric intake: 30-40 kcal/kg/day 2
• Protein intake: 1.2-1.5 g/kg/day (up to 1.5 g/kg/day in critically ill patients) 1, 2
• If three meals daily are insufficient, add early morning and late evening meals 1
• Enteral nutrition improves survival regardless of steroid treatment 1

Vitamin and Mineral Supplementation

All patients require comprehensive micronutrient replacement including vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 1

Treatment Based on Disease Severity

Mild-Moderate Disease (mDF <32, no encephalopathy)

These patients typically improve with abstinence and nutritional support alone and do not require pharmacologic intervention 1

• Monitor closely during hospitalization 1
• If bilirubin decreases or mDF improves during the first week, specific medical interventions beyond nutrition are unlikely to provide benefit 1

Severe Disease (mDF ≥32 or MELD >20)

First-Line: Corticosteroids

Prednisolone 40 mg daily for 28 days (followed by discontinuation or 2-week taper) is the most extensively studied and effective treatment for severe alcoholic hepatitis 1, 2

• Improves 28-day survival: 80-84.6% with steroids vs. 65-65.7% with placebo 1
• Acts by reducing pro-inflammatory cytokines including TNF-α 1

Contraindications to steroids include:

• Active gastrointestinal bleeding 1
• Renal failure 1
• Acute pancreatitis 1
• Uncontrolled infection 1

Response Assessment at Day 7

Treatment response must be evaluated at day 7 using the Lille model or Early Change in Bilirubin Level (ECBL) 1, 2

• Lille score <0.45: Good response with 85% 6-month survival - continue steroids 1, 2
• Lille score >0.45: Poor response with only 25% 6-month survival - discontinue steroids 1, 2
• ECBL positive (bilirubin at day 7 lower than day 1): 82% 6-month survival 1
• ECBL negative: Only 23% 6-month survival 1

Discontinuing steroids in non-responders is critical as infection occurs more frequently in steroid non-responders, and continued steroid exposure increases risk without benefit 1

Alternative: Pentoxifylline

For patients with contraindications to steroids, pentoxifylline 400 mg orally three times daily for 4 weeks can be considered 1

• Primarily reduces risk of hepatorenal syndrome 1
• However, the 2014 STOPAH trial showed no mortality benefit from pentoxifylline, limiting its current role 3, 4

Critical Management Considerations

Renal Protection

Avoid nephrotoxic drugs including diuretics and iodinated contrast agents as acute kidney injury represents early multi-organ failure and dramatically worsens prognosis 2

Infection Surveillance

Monitor continuously for infections which can develop after initial diagnosis and are associated with high mortality, particularly in steroid non-responders 1, 2

Liver Transplantation

For steroid non-responders (Lille score ≥0.45), liver transplantation may offer significantly higher survival than continued medical management alone, though this requires careful patient selection and remains controversial 1, 3, 4, 5

Common Pitfalls to Avoid

• Do not use steroids in mild disease (mDF <32 without encephalopathy) - these patients improve spontaneously and steroid risks outweigh benefits 1
• Do not continue steroids beyond day 7 in non-responders - this only increases infection risk without improving outcomes 1
• Do not neglect nutritional support - it is as important as pharmacologic therapy and improves outcomes independently 1
• Do not allow partial abstinence - patients who attempt to "cut back" rather than stop completely have high recidivism rates and continued disease progression 1