What is the treatment for alcoholic hepatitis?

From the Guidelines

Treatment for alcoholic hepatitis primarily involves complete alcohol cessation, nutritional support, and medications, with corticosteroids being the mainstay of treatment for severe cases, as defined by a Maddrey's Discriminant Function >32 or MELD score >20, according to the most recent guidelines 1.

Key Components of Treatment

• Complete alcohol cessation is crucial for the management of alcoholic hepatitis.
• Nutritional support with 1.2-1.5g/kg/day of protein and 35-40 kcal/kg/day is recommended.
• Corticosteroids, such as prednisolone 40mg daily for 28 days, are the primary treatment for severe alcoholic hepatitis.
• Response to treatment should be assessed after 7 days using the Lille score; if >0.45, steroids should be discontinued due to poor response.
• Pentoxifylline may be considered in patients with contraindications to steroids, though its efficacy is less established.
• N-acetylcysteine can be added to prednisolone to improve short-term survival.
• Management of complications like hepatic encephalopathy, ascites, and infections is essential.
• Long-term abstinence support through counseling and medications like acamprosate or naltrexone significantly improves outcomes.

Important Considerations

• The Lille score is used to assess response to corticosteroid therapy and guide treatment decisions.
• Infection is a significant risk in patients with severe alcoholic hepatitis, and early identification and treatment are critical.
• Liver transplantation may be considered for patients who do not respond to medical treatment, as it can significantly improve survival rates.
• The combination of the MELD and Lille scores is recommended for evaluating short- and medium-term risk of death in patients with severe alcoholic hepatitis 1.

Recent Guidelines and Recommendations

• The French Association for the Study of the Liver and the French Alcohol Society clinical guidelines recommend corticosteroid therapy for patients with severe alcoholic hepatitis, with a strong agreement on the use of the Lille score to assess response to treatment 1.
• The guidelines also recommend the use of N-acetylcysteine in combination with corticosteroids, although the evidence is still limited 1.
• Pentoxifylline is no longer recommended as a treatment for severe alcoholic hepatitis due to its lack of efficacy, as stated in the guidelines with strong agreement 1.

From the Research

Alcoholic Hepatitis Treatment Options

• The treatment of severe alcoholic hepatitis (AH) involves the use of pharmacological interventions, with corticosteroids being the most commonly recommended treatment option 2, 3, 4.
• Corticosteroids have been shown to reduce short-term mortality in patients with severe AH, with a relative risk (RR) of 0.54 (95% credible interval [CrI], 0.39-0.73) 2.
• Pentoxifylline is also used to treat severe AH, although its efficacy is still debated, with some studies showing a reduction in short-term mortality 5, 6.
• The combination of corticosteroids and pentoxifylline may be considered in the treatment of patients with severe AH, as it has been shown to reduce the incidence of hepatorenal syndrome or acute kidney injury and the risk of infection 6.

Treatment Efficacy and Safety

• The efficacy of corticosteroids in reducing short-term mortality has been consistently shown in several studies, with a significant reduction in mortality compared to placebo (OR=0.58; 95% CI, 0.34-0.98; P=0.04) 6.
• Pentoxifylline has been shown to reduce short-term mortality in some studies, although the evidence is not as strong as for corticosteroids 5, 6.
• The safety of corticosteroids and pentoxifylline has been evaluated in several studies, with no significant differences in adverse effects between the two treatments 5, 6.

Current Status and Future Directions

• The current status of corticosteroids and pentoxifylline in the treatment of severe AH is summarized in several reviews and meta-analyses, highlighting the need for further research to improve treatment outcomes 2, 3, 4.
• Future directions in the treatment of severe AH include the development of new pharmacological interventions, such as liver transplantation, and the optimization of current treatment strategies 3.