What is the role of prednisone (Prednisone) in the treatment of acute alcoholic hepatitis?

From the Guidelines

Prednisolone at a dose of 40 mg daily for 28 days is recommended for severe acute alcoholic hepatitis, as it improves short-term survival without any observations of a medium- or long-term survival benefit, as indicated by the most recent and highest quality study 1.

Key Considerations

• The treatment should be considered in patients with a severe form of alcoholic hepatitis, defined by a Maddrey's Discriminant Function score greater than 32 or with hepatic encephalopathy.
• Before starting treatment, patients should be screened for infections, as prednisolone is contraindicated in patients with active bacterial infections, fungal infections, or gastrointestinal bleeding.
• The Lille score should be calculated after 7 days of treatment; if the score is greater than 0.45, indicating non-response, prednisolone should be discontinued to avoid unnecessary side effects.
• Absolute abstinence from alcohol is essential during and after treatment for optimal outcomes.

Treatment Details

• The medication should be tapered gradually over 2-4 weeks to prevent adrenal insufficiency after the initial 28-day course.
• Patients with severe disease should be monitored closely, and the treatment should be adjusted according to their response.
• The combination of N-acetylcysteine and corticosteroids can be offered to patients with a severe form of alcoholic hepatitis, as it may improve short-term survival 1.

Supporting Evidence

• A recent study published in Liver International in 2022 1 supports the use of prednisolone at a dose of 40 mg daily for 28 days in patients with severe acute alcoholic hepatitis.
• Other studies, such as those published in Hepatology in 2020 1 and Clinical and Molecular Hepatology in 2013 1, also support the use of prednisolone in the treatment of severe acute alcoholic hepatitis.
• However, the most recent and highest quality study 1 is prioritized in making this recommendation.

From the Research

Treatment of Acute Alcoholic Hepatitis with Prednisolone

• The use of prednisolone in the treatment of acute alcoholic hepatitis has been studied in several clinical trials 2, 3, 4, 5, 6.
• A study published in The New England Journal of Medicine in 2015 found that prednisolone was associated with a reduction in 28-day mortality, but this reduction did not reach significance 2.
• Another study published in JAMA in 2013 found that the addition of pentoxifylline to prednisolone did not improve 6-month survival in patients with severe alcoholic hepatitis 3.
• A study published in Hepatology International in 2016 found that the combination of prednisolone and S-adenosylmethionine was associated with a better response to therapy and less frequent hepatorenal syndrome compared to prednisolone alone 4.
• A study published in the Journal of Hepatology in 2014 found that pentoxifylline was not non-inferior to prednisolone in terms of 1-month survival in patients with severe alcoholic hepatitis 5.
• A systematic review published in Hepatology in 2025 found that the timing of steroid initiation, tapering regimens, and surveillance of adverse events are important considerations in the management of severe alcohol-associated hepatitis 6.

Dosage and Duration of Prednisolone Treatment

• The most common steroid dosing regimen used in clinical trials is prednisolone 40 mg daily for 28 days 2, 3, 5, 6.
• The optimal duration of prednisolone treatment is not well established, but a two-week steroid taper is commonly used 6.
• The use of prednisolone is associated with adverse events such as infections, gastrointestinal bleeds, and renal impairment, which are more common in the first month of treatment 6.

Comparison with Other Treatments

• Pentoxifylline has been compared to prednisolone in several clinical trials, and the results suggest that prednisolone may be more effective in reducing mortality in patients with severe alcoholic hepatitis 2, 3, 5.
• The combination of prednisolone and S-adenosylmethionine may be more effective than prednisolone alone in improving response to therapy and reducing hepatorenal syndrome 4.