What is the treatment for chronic alcoholic hepatitis?

Treatment of Chronic Alcoholic Hepatitis

For severe alcoholic hepatitis (mDF ≥32 or MELD >20), prednisolone 40 mg daily for 28 days is the recommended pharmacologic treatment, but only after excluding active infection, gastrointestinal bleeding, renal failure, and pancreatitis—and this must be combined with complete alcohol abstinence and aggressive nutritional support providing 30-40 kcal/kg/day with 1.2-1.5 g/kg/day protein. 1, 2

Severity Assessment First

Before initiating any treatment, you must stratify disease severity using validated scoring systems 3, 1:

• Modified Discriminant Function (mDF) ≥32 indicates severe disease requiring pharmacologic intervention 1, 2
• MELD score >20-21 is an alternative threshold for severe disease 1, 2
• Glasgow Alcoholic Hepatitis Score ≥9 predicts high 28-day mortality 3, 2
• The presence of hepatic encephalopathy alone warrants treatment consideration regardless of other scores 1

Without treatment and continued drinking, 90-day mortality reaches 40-50% 3, 4

Universal Treatment Components (All Patients)

Alcohol Abstinence - The Cornerstone

Complete and permanent abstinence from alcohol is absolutely essential—there is no safe amount of alcohol consumption after an episode of alcoholic hepatitis. 1, 4, 2

• Naltrexone or acamprosate may be used in combination with counseling to reduce relapse risk 1
• Patients who return to heavy drinking have far worse prognosis than those who remain abstinent 4

Aggressive Nutritional Support

Nutritional therapy is mandatory and improves survival regardless of steroid treatment 1:

• Caloric intake: 30-40 kcal/kg/day 3, 1, 2
• Protein intake: 1.2-1.5 g/kg/day 3, 1, 2
• If the patient cannot eat due to anorexia or altered mental status, enteral feeding via nasogastric tube should be implemented—parenteral nutrition alone is inadequate 3, 4
• Normal-to-high protein diets are safe and do not increase encephalopathy risk 4

Infection Screening and Prevention

Obtain cultures of blood, urine, and ascites (if present) immediately, regardless of whether fever is present, as infections are both precipitating events and factors leading to poor outcomes 3, 4, 2:

• Fever and elevated white blood cell counts are unreliable indicators of infection in alcoholic hepatitis 4
• The immune response is impaired, placing patients at high risk for bacterial and fungal infections 3
• Continuous monitoring for infections is necessary, as they can develop after initial diagnosis and are associated with high mortality 1, 4

Pharmacologic Treatment for Severe Disease

Corticosteroids (First-Line for Severe Disease)

Prednisolone 40 mg daily for 28 days improves 28-day survival by reducing pro-inflammatory cytokines including TNF-α 1, 2:

• This provides modest improvement in 28-day mortality but no benefit at 90 days or 1 year, largely due to increased infection risk 4, 5
• The European Association for the Study of the Liver and American Association for the Study of Liver Diseases both recommend this regimen for severe disease 1, 2

Absolute Contraindications to Steroids

Do not use corticosteroids if any of the following are present 1:

• Active gastrointestinal bleeding
• Renal failure
• Acute pancreatitis
• Uncontrolled infection
• Active hepatitis B or tuberculosis

Response Assessment at Day 7

Use the Lille score at day 7 to predict treatment response 4, 2:

• Lille score <0.45 indicates good response (85% 6-month survival) 2
• Lille score ≥0.45 indicates poor response (25% 6-month survival) 2
• Discontinue glucocorticoids in non-responders, as infection occurs more frequently in steroid non-responders 1, 4

Enhanced Corticosteroid Regimen

The combination of prednisolone plus N-acetylcysteine (NAC) intravenously over the first 5 days showed the most significant improvement 4:

• 1-month mortality: 8% vs 24% with prednisolone alone 4
• Reduced infections: 19% vs 42% 4

Alternative Considerations

While pentoxifylline has been suggested in some older literature 6, 7, the 2016 STOPAH trial showed no benefit of pentoxifylline on mortality 5. Current guidelines prioritize corticosteroids for severe disease 1, 2.

Critical Management Pitfalls to Avoid

Nephrotoxic Drug Avoidance

Avoid or use diuretics sparingly and do not administer iodinated contrast dye for imaging, as acute kidney injury represents early multi-organ failure and dramatically worsens prognosis 1, 4, 2:

• AKI can develop from infection, intravascular volume depletion, or nephrotoxic drugs 4
• Iodinated contrast significantly increases AKI risk in patients with cirrhosis 4, 2

Systemic Inflammatory Response Syndrome (SIRS)

The presence of SIRS on admission significantly increases risk of multi-organ failure, which carries extremely high mortality 4. This warrants intensive monitoring and aggressive infection management.

Liver Transplantation Consideration

Patients with MELD >26 who fail medical therapy should be considered for liver transplantation, which may be life-saving 4, 7:

• Emerging data support liver transplantation in highly select patients with first episode of severe alcoholic hepatitis who are non-responsive to steroids 7
• Traditional 6-month abstinence requirement cannot be met by patients with severe disease, but protocols are evolving 7

Hospitalization Criteria

Patients with severe alcoholic hepatitis or inadequate social and medical support should be admitted to the hospital to encourage abstinence, restore adequate nutrition, and exclude serious infections 3, 2.