What is the treatment approach for an adult patient with a history of chronic alcohol abuse diagnosed with alcohol-related hepatitis?

Treatment of Alcohol-Related Hepatitis

For severe alcohol-related hepatitis (Maddrey score ≥32 or MELD >20), initiate prednisolone 40 mg/day or methylprednisolone 32 mg/day for one month after ruling out active infection, which improves short-term survival but provides no medium or long-term benefit. 1

Severity Assessment and Risk Stratification

• Calculate disease severity immediately using validated scoring systems: Maddrey Discriminant Function (MDF), MELD score, Glasgow Alcoholic Hepatitis Score, or ABIC score to guide treatment decisions 1, 2
• MDF ≥32 predicts 28-day mortality of 30-50% and defines severe disease requiring pharmacologic intervention 2
• MELD >20 predicts high 90-day mortality and should trigger consideration for aggressive treatment 3, 2
• Combine Lille and MELD scores for optimal short and medium-term mortality prediction, particularly valuable for selecting candidates for fast-track liver transplantation 1

Immediate Management and Infection Screening

• Hospitalize all patients with severe disease to manage complications, ensure abstinence, and exclude serious bacterial infections 3, 2
• Obtain blood, urine, and ascites fluid cultures systematically before initiating any corticosteroid therapy, regardless of fever presence, as infections are common precipitants of decompensation 1, 3
• Maintain high clinical suspicion for bacterial and fungal infections throughout treatment, as fever and elevated white blood cell counts are unreliable indicators in this population 3
• Perform diagnostic paracentesis if ascites is present to exclude spontaneous bacterial peritonitis 4

Corticosteroid Therapy for Severe Disease

• Administer prednisolone 40 mg/day or methylprednisolone 32 mg/day for patients with MDF ≥32 in the absence of uncontrolled infection, severe gastrointestinal bleeding, or other contraindications to corticosteroid use 1
• This improves 1-month survival but provides no benefit at 3 months, 6 months, or beyond, highlighting the urgent need for better therapeutic strategies 1
• Assess treatment response at day 7 using the Lille score: scores ≥0.45 indicate poor response with high 6-month mortality and should prompt discontinuation of corticosteroids 1, 2

N-Acetylcysteine Combination Therapy

• Consider combining N-acetylcysteine with corticosteroids in severe disease, as one randomized study showed improved 1-month mortality (8% vs 24% with prednisolone alone) and reduced infection rates (19% vs 42%) 3
• The combination can be offered to patients with severe alcoholic hepatitis, though it showed no 6-month survival benefit in the primary endpoint 1

Aggressive Nutritional Support

• Provide 35-40 kcal/kg/day with protein intake of 1.2-1.5 g/kg/day (increase to 1.5 g/kg/day in severely ill patients), as nutritional intake is a major determinant of mortality 3, 2
• Patients consuming <21.5 kcal/kg/day have significantly lower survival 3
• If the patient cannot eat due to anorexia or altered mental status, initiate enteral feeding via nasogastric tube, as parenteral nutrition alone is inadequate 3, 2
• Normal-to-high protein diets are safe and do not increase encephalopathy risk in alcohol-related hepatitis 3
• Supplement with B vitamins and folic acid in all patients 2, 4

Nephrotoxic Drug Avoidance and Fluid Management

• Avoid or use diuretics sparingly, as acute kidney injury is an early manifestation of multi-organ failure and can develop from intravascular volume depletion or nephrotoxic drugs 3
• Do not administer iodinated contrast dye for imaging, as this significantly increases acute kidney injury risk in patients with cirrhosis 3, 2
• Maintain careful fluid balance to prevent both volume depletion (precipitating acute kidney injury) and volume overload 3

Liver Transplantation Consideration

• Refer patients with MELD >26 for liver transplantation evaluation, particularly those with good insight into their alcohol use disorder and strong social support 3, 2
• Early liver transplantation may be life-saving in select patients with severe alcoholic hepatitis not responding to medical treatment 3

Alcohol Abstinence: The Cornerstone of Treatment

• Abstinence from alcohol is the absolute cornerstone of treatment and essential for long-term survival 3, 2
• Medical treatment responders with maintained abstinence have 5-year survival of 80%, whereas it is only 50% with alcohol relapse 1
• Implement brief alcohol intervention during hospitalization, which reduces future alcohol consumption by approximately 41 g/week 3
• Arrange extended alcohol counseling and addiction treatment systematically after discharge to maintain abstinence 1
• Even reduction in consumption (not complete abstinence) can potentially provide 5-year survival benefit in patients who resume drinking 1

Management of Mild to Moderate Disease

• For patients with MDF <32 or MELD <20, focus on abstinence counseling and nutritional support without corticosteroids 2
• Prescribe high protein diet supplemented with B vitamins and folic acid 2
• Recognize that even "less severe" cases carry significant mortality (10% at 6 months, 20% at 1 year) 2

Critical Pitfalls to Avoid

• Do not delay severity assessment, as early stratification is crucial for timely intervention 2
• Do not overlook that most patients with alcoholic hepatitis already have underlying cirrhosis at diagnosis, requiring evaluation for portal hypertension complications 3, 2
• Do not prescribe "anti-craving" medication during the first 3 months, as survival in this period is related to severity of liver impairment and early improvement, not alcohol resumption 1
• Recognize that 3-month survival should be the primary endpoint for evaluating new medications, as short-term outcomes are mainly associated with the hepatitis itself rather than alcohol relapse 1