What is the treatment for acute alcoholic hepatitis?

Treatment of Acute Alcoholic Hepatitis

For severe alcoholic hepatitis (MDF ≥32 or MELD >20), initiate prednisolone 40 mg daily for 28 days after excluding active infection, gastrointestinal bleeding, and renal failure, while simultaneously implementing complete alcohol abstinence and aggressive nutritional support with 30-40 kcal/kg/day and 1.2-1.5 g protein/kg/day. 1, 2, 3

Immediate Assessment and Risk Stratification

Severity scoring determines treatment eligibility:

• Calculate MDF (≥32 indicates severe disease requiring pharmacologic therapy) or MELD score (>20 warrants treatment consideration) 1
• Alternative thresholds include Glasgow Alcoholic Hepatitis Score ≥9 or ABIC score category C 1, 2
• Presence of hepatic encephalopathy alone warrants treatment consideration regardless of other scores 2

Screen for infections immediately upon presentation:

• Obtain blood, urine, and ascites cultures (if present) regardless of fever, as fever and elevated WBC are unreliable infection indicators in this population 1, 4
• Infections occur in 12-26% at admission and up to 50% during corticosteroid treatment 1
• SIRS on admission significantly increases multi-organ failure risk with extremely high mortality 1, 4

Universal Treatment Components (All Severity Levels)

Alcohol abstinence is the absolute cornerstone:

• Complete and permanent abstinence is essential—there is no safe amount of alcohol consumption after alcoholic hepatitis 2
• Without abstinence, 90-day mortality reaches 40-50% 1
• Consider naltrexone or acamprosate combined with counseling to reduce relapse risk 2

Aggressive nutritional support is mandatory:

• Provide 30-40 kcal/kg/day with protein 1.2-1.5 g/kg/day (increase to 1.5 g/kg/day in severely ill patients) 1, 4, 2
• Patients consuming <21.5 kcal/kg/day have significantly lower survival 4
• If oral intake inadequate due to anorexia or altered mental status, place feeding tube for enteral nutrition—parenteral nutrition alone is inadequate 1, 4
• Normal-to-high protein diets are safe and do not increase encephalopathy risk 4

Pharmacologic Treatment for Severe Disease

Corticosteroid therapy (when eligible):

• Administer prednisolone 40 mg daily (or methylprednisolone 32 mg daily) for 28 days 1, 2
• Benefits are modest: improves 28-day mortality but provides no survival benefit beyond 28 days or at 90 days/1 year 1, 4

Absolute contraindications to corticosteroids:

• Active uncontrolled infection 1, 2
• Uncontrolled gastrointestinal bleeding 1, 2
• Acute kidney injury with creatinine >2.5 mg/dL 1
• Hepatitis B infection, tuberculosis, or HIV 1
• Acute pancreatitis or multi-organ failure 1, 2

Assess treatment response at day 7:

• Calculate Lille score: <0.45 indicates good response (85% 6-month survival), continue steroids for full 28 days 1, 3
• Lille score >0.45 indicates poor response (25% 6-month survival), discontinue steroids immediately as infection risk increases in non-responders 1, 2, 3

Consider N-acetylcysteine combination therapy:

• Prednisolone plus intravenous N-acetylcysteine over first 5 days showed most significant improvement in 1-month mortality (8% vs 24% with prednisolone alone) and reduced infections (19% vs 42%) 4

Alternative for corticosteroid contraindications:

• Pentoxifylline 400 mg three times daily with meals may be used, though efficacy data are conflicting 1

Critical Management Considerations

Avoid nephrotoxic agents aggressively:

• Avoid or use diuretics sparingly—AKI is an early manifestation of multi-organ failure 1, 4, 3
• Do not administer iodinated contrast dye for imaging, as this significantly increases AKI risk 1, 4, 3
• Avoid aminoglycosides and NSAIDs 1

Hospitalization criteria:

• Admit all patients with jaundice and severe disease (MDF ≥32 or MELD >20) or those with inadequate social/medical support 1
• Hospitalization encourages abstinence, restores nutrition, and excludes serious infections 1

Advanced Therapies for Refractory Disease

Liver transplantation evaluation:

• Refer patients with MELD >26 who have good insight into alcohol use disorder and strong social support for transplant evaluation 1, 4
• Early liver transplantation may be life-saving for highly selected patients not responding to corticosteroids 1, 4
• 90-day mortality is extremely high in this population without transplantation 1

Mild to Moderate Disease (MELD <20, MDF <32)

Conservative management approach:

• Refer for abstinence counseling 1
• Prescribe high-protein diet supplemented with B vitamins and folic acid 1
• No corticosteroid therapy indicated 1

Common Pitfalls to Avoid

• Do not rely on fever or WBC count to exclude infection—maintain high clinical suspicion and culture liberally 1, 4
• Do not continue corticosteroids beyond day 7 in non-responders (Lille >0.45), as this increases infection risk without benefit 1, 2, 3
• Do not use parenteral nutrition as sole nutritional support—enteral feeding is essential 1, 4
• Do not overlook that most patients with alcoholic hepatitis already have underlying cirrhosis at diagnosis 1, 4