What is the optimal management for an adult with alcoholic liver disease, including assessment, treatment of acute alcoholic hepatitis, and long‑term care?

Management of Alcoholic Liver Disease

Alcohol abstinence is the single most important intervention across all stages of alcoholic liver disease and must be achieved through combined pharmacologic and psychosocial approaches, while patients with severe alcoholic hepatitis (mDF ≥32 or MELD >20) require immediate corticosteroid therapy with prednisolone 40 mg daily for 28 days. 1, 2, 3

Initial Assessment and Risk Stratification

Disease Severity Determination

• Calculate Modified Discriminant Function (mDF) score and MELD score immediately to identify severe disease requiring pharmacologic intervention 2, 3
  • Severe disease defined as: mDF ≥32, MELD >20-21, or Glasgow Alcoholic Hepatitis Score (GAHS) ≥9 2, 3
  • Presence of hepatic encephalopathy alone warrants treatment consideration regardless of other scores 2

Infection Screening

• Screen all patients for infections regardless of fever presence with blood, urine, and ascitic fluid cultures (if ascites present) 3
• Infections develop frequently after initial diagnosis and carry high mortality, particularly in steroid non-responders 2, 3

Universal Treatment Components (All Stages)

Alcohol Abstinence Strategies

Pharmacologic interventions:

• Baclofen and acamprosate are recommended first-line medications for achieving abstinence in patients with ALD 1
• Naltrexone or acamprosate may be combined with counseling to reduce relapse risk 2

Psychosocial interventions:

• Brief interventions using the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) lower morbidity and mortality related to drinking 1
• Individual psychotherapy focusing on: accepting lack of control over alcohol, education regarding alcohol dependence, and maintaining abstinence 1
• Group therapy such as Alcoholics Anonymous should continue after discharge to prevent recurrence 1
• Family involvement is essential as alcohol dependence is a dysfunctional family disorder requiring family education and therapy 1

Nutritional Support

Aggressive nutritional therapy is mandatory:

• Caloric intake: 35-40 kcal/kg/day 1, 2, 3
• Protein intake: 1.2-1.5 g/kg/day (increase to 1.5 g/kg/day in critically ill patients) 1, 2, 3
• If three meals daily are inadequate, add early morning and late-night meals 1
• Enteral nutrition improves survival regardless of steroid treatment 2

Vitamin and mineral supplementation:

• Supplement vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc in all patients with nutritional deficiency 1

Critical Nephroprotection

• Avoid all nephrotoxic drugs including diuretics and iodinated contrast agents, as acute kidney injury represents early multi-organ failure and dramatically worsens prognosis 2, 3

Treatment of Severe Alcoholic Hepatitis (mDF ≥32 or MELD >20)

Corticosteroid Therapy

Prednisolone 40 mg daily (or methylprednisolone 32 mg daily) for 28 days improves 28-day survival by reducing pro-inflammatory cytokines including TNF-α 1, 2, 3

Contraindications to corticosteroids:

• Active gastrointestinal bleeding 2
• Renal failure 2
• Acute pancreatitis 2
• Uncontrolled infection 1, 2

Response Assessment at Day 7

Use Lille model or Early Change in Bilirubin Level (ECBL) to assess treatment response 3

• Lille score <0.45 indicates good response (85% 6-month survival) 3
• Lille score >0.45 indicates poor response (25% 6-month survival) - discontinue steroids immediately as infection occurs more frequently in non-responders 2, 3

Adjunctive Therapy

N-acetylcysteine combined with corticosteroids may be offered as it showed 1-month and 3-month survival benefit in one randomized trial, though it did not meet the primary 6-month endpoint 1

Pentoxifylline must NOT be prescribed as multiple randomized studies and meta-analyses demonstrate no survival benefit 1

Long-Term Management of Alcoholic Cirrhosis

Abstinence and Cofactor Management

• Complete abstinence reduces risk of liver-related complications and mortality 1
• Identify and manage cofactors: obesity, insulin resistance, malnutrition, cigarette smoking, iron overload, and viral hepatitis 1
• Ten-year survival is 88% with abstinence versus 73% with alcohol relapse 1

Cirrhosis Complications

• Apply general screening and management recommendations for cirrhosis complications including variceal surveillance, hepatocellular carcinoma screening, and management of ascites and hepatic encephalopathy 1

Branched-Chain Amino Acids

• Long-term supplementation with branched-chain amino acids at 34 g/day reduces hospitalizations due to infection, gastrointestinal bleeding, ascites, and hepatic encephalopathy 1

Liver Transplantation

Standard Liver Transplantation

• Consider liver transplantation if MELD score remains >17 after 3 months of alcohol abstinence in patients with decompensated cirrhosis 4
• Graft and patient survival in ALD are similar to other etiologies, with 80-85% survival at one year 1

Fast-Track Liver Transplantation for Severe Alcoholic Hepatitis

• Fast-track liver transplantation must be considered for patients with severe alcoholic hepatitis not responding to medical therapy 1
• Selection requires rigorous multidisciplinary evaluation in reference transplant centers 1
• Criteria include: first decompensation of liver disease, absolute contraindication or non-response to corticosteroids, and low risk of alcohol relapse 1

Common Pitfalls to Avoid

• Do not delay corticosteroid initiation in severe alcoholic hepatitis while waiting for infection workup to complete - start empiric antibiotics if infection suspected 2, 3
• Do not continue corticosteroids beyond day 7 in non-responders (Lille score >0.45) as this increases infection risk without benefit 2, 3
• Do not use diuretics aggressively in patients with alcoholic hepatitis as acute kidney injury is an early sign of multi-organ failure 2, 3
• Do not neglect addiction treatment - the survival benefit of corticosteroids is lost by 3 months, and long-term outcomes depend entirely on abstinence 1