What is the management of alcohol-induced hepatitis?

Management of Alcohol-Induced Hepatitis

Alcohol abstinence combined with aggressive nutritional support forms the foundation of treatment, with prednisolone 40 mg daily for 28 days reserved for severe disease (Maddrey discriminant function ≥32 or MELD >20) in patients without contraindications. 1, 2, 3

Initial Assessment and Risk Stratification

Severity scoring is mandatory to guide treatment decisions:

• Calculate Maddrey discriminant function (MDF): MDF >32 indicates severe disease with 40-50% mortality within 90 days without treatment 1
• Calculate MELD score: MELD >20 predicts high 90-day mortality 1, 2
• Alternative severity markers: Glasgow alcoholic hepatitis score ≥9 or ABIC score category C also indicate severe disease 1, 3
• Laboratory parameters are more reliable than clinical symptoms for predicting severity 1

Screen for infections immediately, regardless of fever presence:

• Obtain blood, urine, and ascites cultures (if ascites present) before initiating any immunosuppressive therapy 1, 2
• Infections are common due to impaired neutrophil function and dramatically worsen prognosis 1, 3

Universal Treatment Components (All Patients)

Alcohol Abstinence

Complete and permanent abstinence is non-negotiable:

• There is no safe amount of alcohol consumption after alcoholic hepatitis 3
• Consider pharmacologic support: naltrexone or acamprosate combined with counseling to reduce relapse risk 1, 3
• Baclofen can also be used to achieve abstinence 1
• Brief interventions are cost-effective and should be implemented in all patients 1

Aggressive Nutritional Support

Provide high-calorie, high-protein nutrition:

• Target 30-40 kcal/kg/day and 1.2-1.5 g/kg/day protein 1, 2, 3
• If oral intake is inadequate, use enteral feeding via feeding tube—parenteral nutrition alone is inadequate 1
• Enteral nutrition improves survival regardless of steroid treatment 3, 4
• Supplement with vitamins and minerals: vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 1
• Consider more frequent smaller meals if three meals daily are insufficient 1

Treatment Based on Disease Severity

Severe Alcoholic Hepatitis (MDF ≥32 or MELD >20)

Prednisolone 40 mg daily for 28 days is first-line pharmacologic therapy:

• Improves 28-day survival by reducing pro-inflammatory cytokines including TNF-α 3, 5
• Follow with either abrupt discontinuation or 2-week taper 2
• Assess response at day 7 using Lille model: Lille score <0.45 indicates good response (85% 6-month survival), while Lille score >0.45 indicates poor response (25% 6-month survival) 2, 3
• Discontinue steroids immediately in non-responders as infections occur more frequently in this group 3

Absolute contraindications to corticosteroids:

• Active gastrointestinal bleeding 3
• Renal failure 3
• Acute pancreatitis 3
• Uncontrolled infection 3

Consider N-acetylcysteine as adjunctive therapy:

• When added to corticosteroids, decreases hepatorenal syndrome, infection, and short-term mortality 6
• Does not significantly affect 6-month mortality 6

Mild to Moderate Alcoholic Hepatitis (MDF <32)

Supportive care without corticosteroids:

• Abstinence and nutritional support are sufficient 7, 8
• Most patients improve significantly with these measures alone 8
• Long-term outcome depends primarily on maintaining abstinence 8

Critical Management Considerations

Avoid Nephrotoxic Agents

Acute kidney injury represents early multi-organ failure:

• Avoid diuretics in the acute phase 2, 3
• Use caution with iodinated contrast agents for imaging—they increase acute kidney injury risk 1, 2

Monitor for Infections Continuously

Infections can develop after initial diagnosis and carry high mortality:

• Particularly dangerous in steroid non-responders 3
• Infections account for the majority of deaths in the weeks following steroid treatment 4
• Maintain high index of suspicion even without fever 1

Hospitalization Criteria

Admit patients with:

• Severe alcoholic hepatitis (MDF ≥32 or MELD >20) 1
• Inadequate social or medical support 1
• Need for supervised abstinence and nutritional restoration 1

Common Pitfalls to Avoid

• Do not use pentoxifylline: Current evidence does not support its use outside clinical trials 5
• Do not continue steroids beyond day 7 in non-responders: This increases infection risk without benefit 3
• Do not rely on parenteral nutrition alone: Enteral feeding is superior 1
• Do not overlook the majority of patients who have underlying cirrhosis at the time of alcoholic hepatitis diagnosis 1

Long-Term Prognosis

Even with optimal treatment, outcomes remain poor:

• One-year mortality approaches 56% even with treatment 1
• Return to drinking is a major contributor to long-term mortality 1
• Steatosis is reversible with abstinence, but alcoholic hepatitis can persist and progress to cirrhosis even with abstinence 7
• Liver transplantation may be considered in highly selected patients with severe complications, though this remains controversial 7, 6