Steroid Dosing for Severe Alcoholic Hepatitis with Maddrey's Discriminant Function of 34.7
For a patient with severe alcoholic hepatitis and a Maddrey's discriminant function of 34.7, administer prednisolone 40 mg orally daily for 28 days, provided there are no contraindications such as active infection, gastrointestinal bleeding, or renal failure. 1
Understanding Disease Severity
Your patient's Maddrey score of 34.7 places them in the severe alcoholic hepatitis category, as the threshold for severe disease is ≥32. 2 This score historically predicted 20-50% one-month mortality, though recent data shows improved outcomes with modern supportive care (approximately 15-17% mortality). 3
Key point: While 34.7 is above the treatment threshold, it is not in the "very severe" range (>60), where some studies have excluded patients due to extremely poor prognosis. 2
Pre-Treatment Requirements
Before initiating corticosteroids, you must:
- Perform extensive bacteriological examination to rule out active infection, as corticosteroids are contraindicated in the presence of uncontrolled infection. 1
- Exclude other contraindications: uncontrolled gastrointestinal bleeding, multiorgan failure, or serum creatinine >2.5 mg/dL. 2
- Calculate MELD score for additional prognostic information; a MELD >20 also indicates severe disease. 4
Standard Corticosteroid Regimen
Prednisolone 40 mg orally once daily for 28 days is the evidence-based standard regimen recommended by the American Association for the Study of Liver Diseases. 1 Note that prednisolone (not prednisone) is preferred because it does not require hepatic conversion to the active form. 2
After completing the 28-day course, complete discontinuation is appropriate—no taper is required. 1
Critical Day 7 Assessment: Lille Score
On day 7 of treatment, calculate the Lille score to determine treatment response. 4, 1 This dynamic assessment is crucial:
- Lille score <0.45: Patient is responding to therapy; continue prednisolone for the full 28 days. 1
- Lille score ≥0.45: Non-responder; consider discontinuation. 1
- Lille score ≥0.56: Null responder; discontinue corticosteroids immediately as continued therapy provides no benefit and increases infection risk. 1
The Lille score incorporates changes in bilirubin, albumin, creatinine, and prothrombin time from baseline to day 7, providing objective evidence of treatment response. 2
Alternative Therapy
If corticosteroids are contraindicated (active infection, renal failure with creatinine >2.5 mg/dL, uncontrolled bleeding), consider pentoxifylline 400 mg orally three times daily for 4 weeks. 1 However, recent evidence suggests pentoxifylline has limited efficacy compared to corticosteroids. 5
Essential Supportive Care
Regardless of corticosteroid use, provide:
- Aggressive nutritional therapy: Enteral nutrition with 1.2-1.5 g/kg protein and 35-40 kcal/kg daily is critical, as malnutrition worsens outcomes. 1
- Alcohol abstinence counseling: Complete abstinence is mandatory for any chance of long-term survival. 1
- Monitor for infections: Patients on corticosteroids have increased infection risk; maintain high clinical suspicion and low threshold for cultures. 1
- Assess for hepatorenal syndrome and other complications throughout treatment. 2
Common Pitfalls to Avoid
- Do not use prednisone instead of prednisolone—impaired hepatic conversion reduces efficacy. 2
- Do not continue corticosteroids beyond day 7 in non-responders (Lille ≥0.56)—this only increases infection risk without benefit. 1
- Do not neglect nutritional support—it is as important as pharmacotherapy. 1
- Do not assume the patient will respond—approximately 25-40% are non-responders who need alternative strategies. 6, 5
Prognosis
Even with optimal corticosteroid therapy, expect 6-month survival of approximately 70-80% in responders. 1 Non-responders have significantly worse outcomes and may require consideration of emerging therapies (granulocyte colony-stimulating factor, fecal microbiota transplantation) or early liver transplantation evaluation in highly selected cases. 6, 5