From the Guidelines
Treatment for severe alcoholic hepatitis should involve corticosteroid therapy, such as prednisolone 40 mg/day or methylprednisolone 32 mg/day, as it improves short-term survival without any observations of a medium- or long-term survival benefit, as recommended by the French Association for the Study of the Liver and the French Alcohol Society clinical guidelines 1. The management of alcoholic hepatitis is multifaceted, involving abstinence from alcohol, nutritional support, and medication for severe cases.
- Complete abstinence from alcohol is crucial, as continued drinking worsens liver damage and reduces survival.
- Nutritional support with a high-calorie, high-protein diet is essential to address malnutrition.
- For severe alcoholic hepatitis, defined by a Maddrey's Discriminant Function >32 or MELD score >20, corticosteroids like prednisolone 40mg daily for 28 days may be used in patients without contraindications such as active infection, gastrointestinal bleeding, or renal failure.
- The combination of N-acetylcysteine and corticosteroids can be offered to patients with a severe form of alcoholic hepatitis, as it may provide a short-term survival benefit, although confirmatory studies are necessary 1.
- Pentoxifylline should no longer be offered to patients with severe alcoholic hepatitis due to its ineffectiveness, as demonstrated by several recent randomized studies and meta-analyses 1.
- Fast-track liver transplantation should be considered for patients at the end of their therapeutic options, with a rigorous and multidisciplinary selection process in a reference transplant center, as it may improve 6-month survival and maintain a survival benefit at 2 years 1.
- The Lille score should be calculated on the seventh day of treatment to identify patients not responding to treatment, and patients with a Lille score ≥ 0.45 are considered treatment non-responders, with corticosteroid therapy stopped in those with a Lille score ≥ 0.56 1.
- The investigation for infection should be systematically carried out in severe forms of alcoholic hepatitis, and an extensive bacteriological examination must be carried out systematically before initiating corticosteroid therapy 1.
- Combining the Lille and MELD scores is the optimal approach for evaluating short- and medium-term risk of death, and survival in the first 3 months is related to the severity of alcoholic hepatitis and early liver function improvement 1.
- Long-term outcomes depend mainly on achieving abstinence, and addiction treatment must be systematically offered after an episode of alcoholic hepatitis, as abstinence is associated with improved 5-year survival 1.
From the Research
Alcoholic Hepatitis Treatment Overview
- Alcoholic hepatitis is a necrotizing, often inflammatory, process that is an important precursor to the development of cirrhosis 2.
- Severe alcoholic hepatitis (SAH) is defined by modified Maddrey discriminant function ≥32 or Model for End-Stage Liver Disease (MELD) >21 and/or hepatic encephalopathy, with a 3-month mortality rate ≥30-70% 3.
Current Treatment Options
- Corticosteroids have been the standard-of-care therapy, albeit controversial, with recent studies showing that prednisolone was not associated with a significant reduction in 28-day mortality 3, 4.
- Supportive care and abstinence from alcohol are the foundations of therapy, with nutritional supplementation for those patients with markedly reduced caloric intake 4, 2.
- Liver transplantation should be offered to select patients with severe alcoholic hepatitis who are nonresponsive to medical treatment 3, 4.
Emerging Therapies
- A paradigm shift from antiinflammatory therapy such as corticosteroids to liver regeneration treatment, e.g., granulocyte-colony stimulating factor, molecular targeted treatments, and fecal microbiota transplantation, for severe alcoholic hepatitis is taking place 3.
- Several clinical trials are examining the efficacy and safety of new or repurposed compounds in severe AH, targeting various pathways in the pathogenesis of AH: the gut-liver axis, the inflammatory cascade, and liver injury 4.
Prognostication and Scoring Systems
- Combining data from liver disease scoring systems, such as the MELD+Lille combination, better predicts outcomes of patients with alcoholic hepatitis than either static or dynamic models alone 5.
- The joint-effect model accurately predicts patient survival regardless of patient risk level, and may help patient management and design of clinical trials 5.