Corticosteroids, specifically prednisolone or methylprednisolone, are recommended for the treatment of severe alcoholic hepatitis, as they have been shown to improve short-term survival
Indications for steroid use
- The primary indication for corticosteroid therapy is severe alcoholic hepatitis, typically defined by a Maddrey's Discriminant Function (MDF) score greater than 32 or the presence of hepatic encephalopathy
- The American Association for the Study of Liver Diseases (AASLD) 2020 guidelines suggest oral prednisolone 40 mg/day, if not contraindicated, to improve 28-day mortality in patients with severe alcoholic hepatitis (MDF ≥ 32)
- The European Association for the Study of the Liver (EASL) 2018 guidelines recommend corticosteroids (prednisolone 40 mg/day or methylprednisolone 32 mg/day) to reduce short-term mortality in patients with severe alcoholic hepatitis in the absence of active infection
Contraindications for steroid use
- Corticosteroids should not be used in patients with severe alcohol-related hepatitis and acute-on-chronic liver failure (ACLF) or uncontrolled bacterial infection
Monitoring and response assessment
- The response to corticosteroid therapy is often assessed using the Lille model after 7 days of treatment. A Lille score greater than 0.45 indicates a poor response, and discontinuation of corticosteroids should be considered due to the lack of benefit and potential for adverse effects.
- The EASL 2017 guidelines recommend close monitoring for tolerability of the drugs and the development of rare side effects such as lactic acidosis or kidney dysfunction
- Systematic screening for infection before initiating therapy, during corticosteroid treatment, and during the follow-up period in patients with alcoholic hepatitis is recommended by the EASL 2018 guidelines
Efficacy of steroids
- A randomized clinical trial showed that corticosteroids in the form of prednisolone 30 mg daily are superior to a broad antioxidant cocktail in the treatment of severe alcoholic hepatitis
- However, a worldwide study found that the use of corticosteroids was associated with increased 30-day survival but not 90- or 180-day survival. The maximal benefit was observed in patients with a Model for End-Stage Liver Disease (MELD) score between 25–39. This benefit was lost in patients with the most severe liver disease (MELD score higher than 51)
In conclusion, corticosteroids are a cornerstone in the treatment of severe alcoholic hepatitis, but their use requires careful patient selection and monitoring for potential side effects and contraindications.