When should I consider steroids in my patient with alcoholic hepatitis?

The short answer is not very often! In the treatment of alcoholic hepatitis (AH), steroids are reserved for a narrow group of patients only, with a 2018 meta-analysis finding a reduction in short-term mortality (average 36%) at 28 days but not at 6 months.1

The most studied scoring system to help clinicians decide whether a patient should get steroids is the Maddrey’s Discriminant Function (MDF), which is based on the prothrombin and total bilirubin. A score of ≥32 indicates severe disease and potential response to steroids, while a score <32 indicates mild to moderate disease, for which the risk of steroids (e.g. infection, worsening ulcer disease/bleeding, and glucose intolerance) may outweigh any potential benefit.

However, even with a score ≥32, the likelihood of patient adherence to 28 days of steroid therapy, risk of infection and other steroid-related complications should be carefully considered in individual patients. It’s also important to note that a 2008 meta-analysis showed that patients with a very high MDF score of >54 actually had higher mortality rates with steroid therapy, possibly related to the lack of response in very advanced disease as well as high infection risk.2

Many clinicians also use the Lille’s score to help determine whether a patient is a responder after 7 days of initial therapy. A score >0.45 (calculated based on bilirubin levels at day 0 and 7 and other initial labs and age) indicates poor response and that steroids may be stopped due to its risks.3

Based on the result of a small retrospective study, Glasgow Alcoholic Hepatitis (GAH) score has also been suggested as a means of further defining patients with a MDF ≥32 who may potentially benefit from steroids (ie, score ≥9).4

Bonus pearl: Did you know that pentoxifylline, a tumor necrosis factor (TNF), has generally not been found to be effective in the treatment of AH?5,6

Contributed by Tom Wang, MD, Mass General Hospital, Boston, MA.

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References

  1. Louvet A, et al. “Corticosteroids reduce risk of death within 28 days for patients with severe alcoholic hepatitis, compared with pentoxifylline or Placebo—a meta-analysis of individual data from controlled trials.” Gastroenterology 2018; 155: 458-468. https://www.sciencedirect.com/science/article/abs/pii/S0016508518344950
  2. Rambaldi A, et al. “Systematic review: glucocorticosteroids for alcoholic hepatitis–a Cochrane Hepato‐Biliary Group systematic review with meta‐analyses and trial sequential analyses of randomized clinical trials.” Alimentary pharmacology & therapeutics 2008; 27: 1167-1178. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2008.03685.x
  3. Louvet A, et al. “The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids.” Hepatology 2007; 45: 1348-1354. https://www.ncbi.nlm.nih.gov/pubmed/17518367
  4. Forrest EH, et al. “Analysis of factors predictive of mortality in alcoholic hepatitis and derivation and validation of the Glasgow alcoholic hepatitis score.” Gut 2005; 54: 1174-1179. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774903/
  5. Thursz MR, et al. “Prednisolone or pentoxifylline for alcoholic hepatitis.” N Engl J Med 2015; 372: 1619-1628. https://www.nejm.org/doi/full/10.1056/NEJMoa1412278
  6. Parker R. “Systematic review: pentoxifylline for the treatment of severe alcoholic hepatitis.” Alimentary Pharm Therapeutics 2018; 37: 845-854. https://onlinelibrary.wiley.com/doi/10.1111/apt.12279

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

When should I consider steroids in my patient with alcoholic hepatitis?