Management of Alcoholic Hepatitis with Ongoing Alcohol Use
Immediate Priority: Calculate Severity and Screen for Corticosteroid Candidacy
Your patient requires immediate calculation of the Maddrey Discriminant Function (mDF) and MELD score to determine if corticosteroids are indicated, followed by mandatory infection screening before any steroid initiation. 1
Severity Assessment
Calculate mDF = 4.6 × (PT – control PT) + total bilirubin (mg/dL): With PT 12.5 (assuming control
11), this yields mDF ≈ 7.9 + 1.1 = **9**, which is below the threshold of 32 for severe alcoholic hepatitis 1Calculate MELD score using bilirubin 1.1, INR (derived from PT 12.5), and creatinine 0.87: This patient's MELD is likely well below 20, the threshold for severe disease 1, 2
This patient does NOT meet criteria for corticosteroid therapy because both mDF <32 and MELD <20 indicate mild-to-moderate disease with lower short-term mortality risk 3, 1
Key Diagnostic Confirmation
The AST 108 with normal ALT 34 gives an AST/ALT ratio of 3.2, which strongly supports alcoholic hepatitis (ratio >1.5 is diagnostic) 3, 4
Positive urine bilirubin and mildly elevated PT confirm hepatic dysfunction consistent with ongoing alcohol-related liver injury 3
The pattern of macrocytosis (MCV 99) and borderline thrombocytopenia (149) are classic for chronic alcohol toxicity and do not require additional workup beyond B12/folate 5, 6
Comprehensive Management Strategy for Non-Severe Alcoholic Hepatitis
1. Absolute Alcohol Abstinence (The Single Most Critical Intervention)
Complete and permanent abstinence from alcohol is the cornerstone of treatment and the only intervention proven to prevent progression to cirrhosis and death. 3, 4, 2
There is no safe amount of alcohol after an episode of alcoholic hepatitis; even patients who "cut back" have significantly higher recidivism and progression rates 3
Continued drinking places this patient at 40-50% risk of 90-day mortality if disease progresses to severe alcoholic hepatitis 1
Pharmacologic support for abstinence: Offer naltrexone 50 mg daily or acamprosate 666 mg three times daily in combination with intensive counseling, as both reduce relapse rates in detoxified alcoholics 3, 4
Consider baclofen (GABA-B agonist) as an alternative, which has shown benefit in achieving abstinence specifically in patients with cirrhosis 3
Immediate referral to addiction medicine, behavioral health, or structured alcohol treatment program is mandatory 1
2. Aggressive Nutritional Support
Provide 30-40 kcal/kg/day and 1.2-1.5 g protein/kg body weight daily, preferably via enteral route 1, 4, 2
Nutritional therapy improves survival independent of any pharmacologic treatment and should be implemented immediately 2
Thiamine 500 mg IV three times daily for 3-5 days before any glucose-containing fluids to prevent Wernicke's encephalopathy 1
Check and replete vitamin B12 and folate levels, as deficiencies contribute to macrocytosis and anemia 5
3. Close Monitoring for Disease Progression
Repeat CMP, CBC, and PT/INR in 2 weeks (not 2-4 weeks) to detect early progression to severe disease 1
Red flags requiring emergency evaluation include:
If mDF rises to ≥32 or MELD rises to >20, the patient becomes a candidate for corticosteroids only after infection is excluded 1, 2
4. Rosuvastatin Management in Active Liver Disease
Continue rosuvastatin 40 mg daily with close monitoring, as the lipid response is excellent and statins may have hepatoprotective effects in liver disease 1
Common pitfall: Many clinicians inappropriately discontinue statins in liver disease; elevated transaminases alone are not a contraindication unless AST/ALT exceed 3× upper limit of normal 1
Monitor liver enzymes every 2-4 weeks initially given the underlying hepatitis 1
5. Subclinical Hypothyroidism Management
Repeat TSH in 6-8 weeks and check TPO antibodies as planned 1
Do not initiate levothyroxine unless TSH rises above 10 or symptoms develop, as subclinical hypothyroidism with TSH 5.19 does not require treatment 1
6. Infection Vigilance
Patients with alcoholic hepatitis have profoundly impaired immune function and 20-30% develop infections that trigger multi-organ failure. 1, 4
Maintain low threshold for blood cultures, urinalysis with culture, and chest X-ray if any clinical deterioration occurs 1
Infections are the primary driver of mortality in alcoholic hepatitis and can develop at any time during the disease course 1, 2
What NOT to Do
Do NOT start corticosteroids in this patient with mild disease (mDF <32, MELD <20), as steroids provide no benefit and increase infection risk in non-severe cases 3, 1
Do NOT order ERCP, MRI, or MRCP unless biliary obstruction is suspected; these delay essential therapy and are not indicated for intra-hepatic alcoholic hepatitis 1
Do NOT use acetaminophen for pain control given the liver disease; avoid all hepatotoxic medications 7
Do NOT use nephrotoxic agents including NSAIDs, diuretics (unless ascites develops), or iodinated contrast, as acute kidney injury dramatically worsens prognosis 2
Addressing the Core Clinical Challenge: Patient Refusal of Abstinence
Document extensively that continued alcohol use will lead to cirrhosis, liver failure, and death, and that no medical therapy can substitute for abstinence. 3, 4
Frame the conversation around specific mortality risk: "Without stopping alcohol completely, you have a 40-50% chance of dying within 3 months if your liver disease worsens to severe alcoholic hepatitis" 1
Offer same-day addiction medicine consultation or warm handoff to substance use treatment 1
Consider motivational interviewing techniques and harm-reduction approaches if complete abstinence is initially refused 3
Naltrexone or acamprosate should be offered even if the patient is ambivalent, as these medications reduce craving and may facilitate eventual abstinence 3, 4
Document the patient's understanding and refusal in detail, including specific risks discussed 1
Prognosis and Long-Term Outlook
With continued drinking: Progression to cirrhosis is nearly inevitable, with 5-year survival dropping to approximately 50% 4
With complete abstinence: Even patients with established alcoholic hepatitis can achieve 80% 5-year survival if abstinence is maintained 4
The AST/ALT pattern may normalize with abstinence, but this does not indicate resolution of underlying liver damage 8
Macrocytosis and thrombocytopenia typically improve within 2-5 days of abstinence, providing an objective marker of compliance 5, 6