What is the treatment for alcoholic hepatitis and is it curable?

Treatment and Curability of Alcoholic Hepatitis

Alcoholic hepatitis is not curable in the traditional sense, but it is treatable and potentially reversible with complete alcohol abstinence combined with appropriate medical therapy for severe cases. 1, 2

Is It Curable?

Alcoholic hepatitis represents acute inflammatory liver injury that can improve or resolve, but the underlying liver disease (often cirrhosis) typically persists. The concept of "cure" depends on disease severity and abstinence:

• With abstinence and treatment response: Medical treatment responders who maintain complete abstinence achieve approximately 80% 5-year survival rates 2
• With alcohol relapse: Survival drops to approximately 50% even in treatment responders who resume drinking 2
• Without treatment in severe disease: 28-day mortality reaches 40-50% 1, 3

The majority of patients presenting with alcoholic hepatitis already have underlying cirrhosis, making complete "cure" unlikely, though significant improvement and long-term survival are achievable 1

Treatment Algorithm by Disease Severity

Universal Treatment for All Patients (Mild and Severe)

Alcohol Abstinence - This is the single most important intervention for improving survival 1:

• Complete and permanent abstinence is required; there is no safe amount of alcohol after alcoholic hepatitis 3
• Use pharmacologic support: naltrexone or acamprosate combined with counseling to reduce relapse risk 3
• Consider baclofen and acamprosate specifically for maintaining abstinence 4
• Implement brief interventions using the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) 4

Aggressive Nutritional Support 1, 3:

• Provide 30-40 kcal/kg/day with 1.2-1.5 g/kg/day protein 4, 3
• Enteral nutrition improves survival regardless of steroid treatment 3
• Supplement with thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, zinc, and vitamin A 4

Infection Screening and Prevention 1, 4, 2:

• Screen all patients for infections regardless of fever presence with blood, urine, and ascites cultures (if present) 4
• The immune response is severely impaired in alcoholic hepatitis, creating high infection risk 2
• Infections can develop after initial diagnosis and are associated with high mortality 3

Severity Assessment (Required Before Treatment Decisions)

Use validated scoring systems to determine disease severity 1, 4:

• Maddrey Discriminant Function (mDF) ≥32: Indicates severe disease requiring corticosteroids 1, 3
• MELD score >20: Predicts high 90-day mortality 1, 3
• Glasgow Alcoholic Hepatitis Score ≥9: Predicts high 28-day mortality 1, 3
• ABIC score category C: Predicts high 28- and 90-day mortality 1

The mDF and MELD scores are the most useful for determining prognosis and guiding treatment decisions 1

Treatment for Severe Alcoholic Hepatitis (mDF ≥32 or MELD >20)

First-Line Pharmacologic Therapy - Corticosteroids 1, 2, 3:

• Prednisolone 40 mg daily for 28 days (or methylprednisolone 32 mg daily) 2, 3
• Improves 28-day survival by reducing pro-inflammatory cytokines including TNF-α 3
• Assess treatment response at day 7 using Early Change in Bilirubin Level (ECBL) or Lille score 1
• Critical: Discontinue steroids in non-responders (Lille score >0.45), as infections occur more frequently in steroid non-responders 3

Contraindications to Corticosteroids 3:

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

Alternative or Adjunctive Therapy 1:

• Pentoxifylline: Alternative treatment that can improve survival in severe alcoholic hepatitis when steroids are contraindicated 1
• N-acetylcysteine combined with corticosteroids: May improve short-term (1-month) survival from 24% to 8% mortality, though 3-month and 6-month survival rates show no significant difference 1, 2
• The combination reduced hepatorenal syndrome deaths from 22% to 9% 1

Treatment for Mild Alcoholic Hepatitis (mDF <32, MELD <20)

Supportive Care Without Corticosteroids 4:

• Focus on abstinence support, nutritional therapy, and infection prevention
• Admit patients with inadequate social/medical support to encourage abstinence, restore nutrition, and exclude serious infections 4
• Monitor closely as mild disease can progress to severe disease, particularly with continued alcohol consumption 4

Critical Management Considerations

Avoid Nephrotoxic Agents 4, 3:

• Avoid diuretics and iodinated contrast agents
• Acute kidney injury represents early multi-organ failure and dramatically worsens prognosis 3

Monitor for Treatment Response and Complications 1:

• Use ECBL or Lille score during steroid treatment to identify high-mortality-risk patients 1
• Combining Lille and MELD scores provides optimal prediction of short and medium-term mortality 2
• Screen for systemic inflammatory response syndrome (SIRS), which increases multi-organ failure risk 4

Liver Transplantation 1:

• Consider for steroid non-responders or those with decompensated cirrhosis (CTP class C) 1
• Survival rates after transplantation for alcoholic liver disease are similar to or higher than other causes 1
• Traditional 6-month abstinence requirement is being reconsidered, as it poorly predicts post-transplant recidivism 1

Common Pitfalls

Do not underestimate nutritional therapy: Malnutrition significantly impacts outcomes and must be aggressively addressed 4

Do not assume mild disease will always recover with abstinence alone: Close monitoring remains essential as progression can occur 4

Do not continue steroids in non-responders: This increases infection risk without benefit 3

Do not use anti-TNF-α agents: Infliximab and etanercept are associated with higher mortality rates due to increased serious infections 1

Recognize the limitation of corticosteroids: They improve only short-term (28-day) survival with no significant benefit at 3 months and beyond 2

Long-Term Outcomes

The 1-year mortality rate remains approximately 56% even with current treatments, and the 4-year mortality rate for alcoholic hepatitis superimposed on cirrhosis reaches 65% 1. Long-term survival depends almost entirely on maintaining complete alcohol abstinence 2, 3. Addiction treatment must be systematically offered after an episode of alcoholic hepatitis to improve long-term outcomes 2.