From the Guidelines
For severe alcoholic hepatitis, I recommend prednisolone 40mg daily for 28 days, followed by a taper, as this approach has been shown to improve 28-day mortality in patients with severe AH (MDF ≥32) without contraindications to the use of corticosteroids 1. The treatment should be guided by the patient's response, with the Lille score used to reassess prognosis and guide treatment course after 7 days of corticosteroids 1.
- Before starting treatment, calculate the patient's Maddrey's Discriminant Function (DF) score; prednisolone is typically indicated when the score exceeds 32 or if hepatic encephalopathy is present.
- Monitor for response using the Lille score at day 7; if greater than 0.45, consider discontinuing steroids as the patient may not benefit from continued treatment 1.
- After the initial 28-day course, taper the prednisolone over 2-3 weeks by reducing the dose by 5-10mg every 3-5 days to minimize adrenal suppression while gradually withdrawing the anti-inflammatory effects. Throughout therapy, closely monitor for infections, hyperglycemia, and gastrointestinal bleeding, which are common complications of steroid therapy in these patients.
- Concurrent alcohol abstinence counseling and nutritional support are essential components of the overall management plan, with abstinence being key to long-term survival 1.
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.
- A study published in 2016 found that the combination of prednisolone and S-adenosylmethionine (SAMe) was associated with better therapy response and less frequent hepatorenal syndrome (HRS) occurrence compared to prednisolone alone 2.
- Another study published in 2015 found that prednisolone was associated with a reduction in 28-day mortality, but this reduction did not reach significance 3.
- A 2013 study found that the addition of pentoxifylline to prednisolone did not result in improved 6-month survival compared to prednisolone alone 4.
- A 2014 study found that pentoxifylline was not statistically equivalent to prednisolone in terms of efficacy, supporting the use of prednisolone as a preferred treatment option in patients with severe alcoholic hepatitis 5.
Tapering of Prednisolone
- A 2025 systematic review of randomized controlled trials found that a two-week steroid taper was the most frequently reported regimen 6.
- The review recommended the lowest possible steroid exposure with a two-week steroid taper and close outpatient follow-up 6.
- The review also recommended vigilant monitoring in the first month of treatment, as most infections occurred within this time period 6.