What is the treatment approach for a patient with alcoholic hepatitis?

Treatment of Alcoholic Hepatitis

The treatment approach for alcoholic hepatitis is stratified by disease severity: all patients require immediate alcohol abstinence, aggressive nutritional support, and infection screening, while those with severe disease (MDF >32 or MELD >20) should receive prednisolone 40 mg daily for 28 days unless contraindicated, in which case pentoxifylline or early liver transplantation evaluation should be considered. 1, 2

Immediate Universal Interventions for All Patients

Alcohol abstinence is the absolute cornerstone of treatment and must be achieved immediately. 1, 3 Complete lifelong abstinence is the only acceptable recommendation, as there is no safe amount of alcohol consumption after an episode of alcoholic hepatitis. 4, 2

Pharmacologic Support for Abstinence

• Baclofen is the only anti-craving medication that should be used in patients with alcoholic liver disease, as it has been formally tested in cirrhotic patients and demonstrates safety at doses not exceeding 80 mg/day. 4
• Acamprosate represents a safe alternative with no hepatotoxicity risk at 1,998 mg/day for 3-6 months. 4
• Naltrexone must be completely avoided due to significant hepatotoxicity risk in alcoholic liver disease. 4, 5
• Immediate referral to Alcoholics Anonymous with active encouragement for regular attendance is essential. 4
• Cognitive behavioral therapy should be implemented, particularly in patients with comorbid depression. 4

Infection Screening and Prevention

All patients with jaundice and suspected alcoholic hepatitis must have cultures of blood, urine, and ascites (if present) to determine bacterial infections regardless of whether fever is present. 1, 3 The immune response is impaired in these patients, placing them at high risk for infections that can trigger multi-organ failure. 1

Aggressive Nutritional Support

Patients require 30-40 kcal/kg body weight and 1.2-1.5 g protein/kg body weight daily for adequate recovery. 1, 3, 2 If the patient cannot eat due to anorexia or altered mental status, enteral feeding via feeding tube should be implemented—parenteral nutrition alone is inadequate. 1 Supplement with B vitamins, folic acid, vitamin A, thiamine, vitamin B12, pyridoxine, vitamin D, and zinc. 3

Severity Assessment

Disease severity must be determined using validated scoring systems to guide pharmacologic treatment decisions. 1, 3, 2

• Maddrey discriminant function (MDF) >32 predicts high mortality within 28 days and indicates severe disease requiring treatment. 1, 2
• MELD score >20 predicts high 90-day mortality and defines severe disease. 1, 2
• ABIC score category C and Glasgow alcoholic hepatitis score ≥9 are alternative severity indicators. 1, 2
• The presence of hepatic encephalopathy alone warrants consideration of treatment regardless of other scores. 2

Treatment Based on Severity

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

Prednisolone 40 mg daily for 28 days is the first-line pharmacologic treatment for severe disease and improves 28-day survival by reducing pro-inflammatory cytokines including TNF-α. 2 However, methylprednisolone does not improve survival beyond 28 days, and benefits for <28 days are modest. 1

Contraindications to Corticosteroids

Steroids are contraindicated in patients with: 2

• Active gastrointestinal bleeding
• Renal failure
• Acute pancreatitis
• Uncontrolled infection
• Hepatitis B viral infection
• Tuberculosis or other serious infectious diseases 1

Alternative for Steroid-Contraindicated Patients

Patients with contraindications to glucocorticoids may be treated with pentoxifylline 400 mg three times daily with meals, though data regarding efficacy are conflicting. 1

Liver Transplantation Consideration

Patients with severe alcoholic hepatitis, particularly those with MELD score >26 with good insight into their alcohol use disorder and good social support, should be referred for evaluation for liver transplantation, as the 90-day mortality rate is very high. 1 Recent data demonstrate that early liver transplantation in carefully selected patients who fail medical therapy provides significant survival benefit with 6-month survival rates of 77-100%. 6

Mild to Moderate Alcoholic Hepatitis (MDF <32 and MELD <20)

Patients with mild to moderate disease should receive abstinence counseling, high-protein diet supplemented with B vitamins and folic acid, and close monitoring without corticosteroids. 1, 3

Patients with inadequate social and medical support should be admitted to the hospital to encourage abstinence, restore adequate nutrition, and exclude serious infections. 1, 3

Critical Management Considerations

Nephrotoxic Drug Avoidance

Nephrotoxic drugs, including diuretics, should be avoided or used sparingly, as acute kidney injury is an early manifestation of multi-organ failure. 1, 2 Iodinated contrast agents should be used with caution as they increase risk of acute kidney injury. 1, 3

Monitoring for Complications

The presence of systemic inflammatory response syndrome (SIRS) on admission is associated with increased risk of multi-organ failure syndrome. 1, 3 Development of multi-organ failure, usually due to infections developing after initial diagnosis, is associated with very high mortality. 1

Discontinuing steroids in non-responders is critical, as infection occurs more frequently in steroid non-responders. 2 The Lille score should be used to determine response to steroids. 7

Mental Health Management

Patients with alcoholic hepatitis and comorbid depression require immediate mental health referral, even if they currently deny suicidal ideation, as depression significantly increases relapse risk. 4 Assessment of depression symptoms and suicide risk should be performed at each visit. 4

Common Pitfalls

• Do not underestimate the importance of nutritional therapy—malnutrition significantly impacts outcomes and must be aggressively addressed. 3
• Do not assume mild alcoholic hepatitis will always recover with abstinence alone—patients can progress to severe disease, particularly if alcohol consumption continues. 3
• Do not delay implementation of abstinence support strategies—early intervention with pharmacotherapy and psychosocial support improves outcomes. 3, 4
• Do not use naltrexone in patients with alcoholic liver disease—it poses significant hepatotoxicity risk. 4, 5
• Without treatment and abstinence, the mortality rate within 90 days is 40-50%. 1