Steroid Treatment for Severe Alcoholic Hepatitis

Diagnosis and Assessment

The American Association for the Study of Liver Diseases recommends that severe alcoholic hepatitis be defined by a Maddrey Discriminant Function (mDF) score ≥32, MELD score >21, Glasgow Alcoholic Hepatitis Score (GAHS) ≥9, or presence of hepatic encephalopathy 1, 2
Patients with mild alcoholic hepatitis (mDF <32, MELD <18, GAHS <8) generally improve with abstinence and supportive care alone, as suggested by the American Association for the Study of Liver Diseases 3, 4

The American College of Gastroenterology recommends prednisolone 40 mg daily for 28 days as the standard treatment regimen for severe alcoholic hepatitis 1, 2, 5
Steroid therapy has been shown to improve short-term (28-day) survival in patients with severe alcoholic hepatitis, according to the American Association for the Study of Liver Diseases 1, 2

The American College of Gastroenterology states that steroids are contraindicated in patients with active infection or sepsis, gastrointestinal bleeding, acute renal failure, or acute pancreatitis 1, 2, 5

The Lille model score is used to assess early response to steroid treatment, categorizing patients as complete responders (score ≤0.16), partial responders (score 0.16-0.56), or null responders (score ≥0.56), as recommended by the American Association for the Study of Liver Diseases 5
The 28-day survival rates based on Lille score are 91.1% for complete responders, 79.4% for partial responders, and 53.3% for null responders, according to the American College of Gastroenterology 5

For patients with mDF ≥32 without contraindications, the American College of Gastroenterology recommends starting prednisolone 40 mg daily for 28 days and assessing response at day 7 using the Lille model 1, 5
If Lille score <0.56 (responder), the American Association for the Study of Liver Diseases suggests continuing prednisolone for the full 28-day course and considering tapering over 2 weeks after completion 5, 7

The American College of Gastroenterology states that pentoxifylline 400 mg three times daily for 28 days can be considered as an alternative to prednisolone in patients with contraindications to steroids, although it is less effective 5, 6, 8, 9
N-acetylcysteine with corticosteroids may improve short-term survival at 1 and 3 months, but is not consistently recommended due to the need for confirmatory studies, according to the American Association for the Study of Liver Diseases 6

The American Association for the Study of Liver Diseases recommends that long-term outcomes depend primarily on achieving alcohol abstinence, which should be strongly recommended to all patients 3, 2, 6
The 6-month survival rate is 82% in patients with confirmed Early Change in Bilirubin Level (ECBL) but only 23% in those without ECBL, as reported by the American College of Gastroenterology 5, 10