Treatment of Alcoholic Hepatitis
For severe alcoholic hepatitis (MDF ≥32 or MELD >20), initiate prednisolone 40 mg daily for 28 days after ruling out active infection, gastrointestinal bleeding, renal failure, and acute pancreatitis, and assess treatment response at day 7 using the Lille score to determine whether to continue or stop corticosteroids. 1, 2, 3
Initial Assessment and Risk Stratification
Calculate disease severity immediately using validated scoring systems to guide treatment decisions 1, 3:
- Maddrey Discriminant Function (MDF) ≥32 indicates severe disease requiring pharmacologic intervention 1, 3
- MELD score >20 is an alternative threshold for severe disease 1, 3
- Presence of hepatic encephalopathy alone warrants treatment consideration regardless of other scores 3
Screen for contraindications to corticosteroids before initiating therapy 1, 2:
- Obtain blood cultures, urine cultures, chest radiograph, and ascites fluid culture (if ascites present) 1, 2
- Rule out active gastrointestinal bleeding, uncontrolled infection, renal failure, and acute pancreatitis 1, 2, 3
Treatment Algorithm by Disease Severity
Severe Disease (MDF ≥32 or MELD >20)
Start prednisolone 40 mg orally daily (or methylprednisolone 32 mg IV daily) for 28 days if no contraindications exist 1, 2, 3. This improves 28-day survival by reducing pro-inflammatory cytokines including TNF-α 3.
Assess treatment response at day 7 using the Lille score, which incorporates age, albumin at day 0, change in bilirubin from day 0 to day 7, renal function, bilirubin at day 0, and prothrombin time 1, 2:
- Lille score <0.45: Continue prednisolone for full 28 days (85% 6-month survival expected) 2
- Lille score 0.45-0.56: Consider stopping prednisolone on case-by-case basis (79.4% 28-day survival) 2
- Lille score ≥0.56: Stop prednisolone immediately (53.3% 28-day survival, no benefit from continued steroids, only increased infection risk) 2
Critical pitfall: Continuing steroids in non-responders (Lille ≥0.56) exposes patients to infection risk without survival benefit and delays consideration of early liver transplantation evaluation 2.
Mild-Moderate Disease (MDF <32, MELD <18, no hepatic encephalopathy)
Provide supportive care and abstinence support without corticosteroids, as these patients will likely improve spontaneously, particularly if bilirubin decreases during hospitalization 4.
Universal Treatment Components for All Patients
Alcohol Abstinence (Most Critical)
Mandate complete and permanent abstinence from alcohol - there is no safe amount of alcohol consumption after an episode of alcoholic hepatitis, as the disease can persist or redevelop 4, 3. Continued alcohol use is associated with disease progression, and 5-year survival drops from approximately 80% with abstinence to approximately 50% with relapse 4, 1.
Prescribe naltrexone or acamprosate in combination with counseling to decrease likelihood of relapse in patients who achieve abstinence 4, 3. In patients with cirrhosis, baclofen may be considered as it has shown benefit in achieving and maintaining abstinence 4.
Aggressive Nutritional Support
Provide 30-40 kcal/kg/day and 1.2-1.5 g protein/kg/day via enteral route, as enteral nutrition improves survival regardless of steroid treatment 1, 2, 3.
Supplement with thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 2.
Infection Surveillance
Monitor continuously for infections, as they develop in 25% of patients during the first month of corticosteroid treatment and are associated with increased short-term mortality 1, 2. Repeat bacteriological examination if symptoms or signs of infection develop during treatment 1.
Renal Protection
Avoid nephrotoxic drugs including diuretics and iodinated contrast agents, as acute kidney injury represents early multi-organ failure and dramatically worsens prognosis 3.
Monitoring and Prognosis
Combine Lille and MELD scores for optimal mortality risk prediction, integrating both baseline severity and early treatment response 1, 2.
Long-term outcomes depend primarily on maintaining abstinence, with medical treatment responders having 5-year survival rates of approximately 80% if abstinence is maintained 1.
Therapies to Avoid
Do not use pentoxifylline as an alternative or adjunct to corticosteroids, as multiple large trials show no survival benefit and no reduction in hepatorenal syndrome 2.
Do not continue corticosteroids beyond day 7 in non-responders (Lille score >0.45), as this only increases infection risk without improving survival 2.
Consideration for Liver Transplantation
Evaluate for early liver transplantation in carefully selected patients with Lille score ≥0.45 who are null responders to corticosteroids, as novel therapies are urgently needed for this population 2.