Prognosis and treatment of patients with acute alcoholic hepatitis

Abstract

Despite alcoholic hepatitis (AH) is the most acute manifestation of alcohol-related liver disease, its treatment remains controversial. Corticosteroids, given either as monotherapy or together with N-acetylecysteine, have been associated with a moderate short-term survival benefit in patients with severe disease. The Maddrey’s discriminant function; Glasgow alcoholic hepatitis score; age, bilirubin, INR and creatinine score; and the Model for end-stage liver disease have been proposed for stratifying prognosis in AH enabling selection of the patients to treat. Definition of treatment non-responders using the Lille model after 7 days of therapy may prevent a detrimental impact of prolonged corticosteroids. Pentoxifylline is an effective alternative reducing the occurrence of hepatorenal syndrome. Emerging evidence supports use of liver transplantation in a strictly selected subset of corticosteroid non-responders.

Keywords::

• alcoholic hepatitis
• corticosteroids
• Lille score
• liver transplantation
• mortality
• pentoxifylline
• prognosis
• prognostic scores
• steroids

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Alcoholic hepatitis (AH) is the most florid and, particularly if severe, potentially fatal manifestation of alcohol-related liver disease.

• Corticosteroids represent the only therapeutic option currently associated with a short-term survival benefit in patients with severe AH.

• Due to the potential systemic complications related to the use of corticosteroids, mainly occurrence of sepsis, decision for treating with corticosteroids should be accurately weighted on a risk–benefit basis.

• Stratification of patients according to the risk of short-term mortality is paramount to enable selection of the patients to treat. For this purpose, several prognostic scores have been specifically developed or tested in a setting of AH: Maddrey’s discriminant function; Glasgow AH score; Age, Bilirubin, International normalized ratio and Creatinine score and the model for end-stage liver disease.

• Evaluation of a Lille response after 1 week of therapy is currently the best validated dynamic criterion to allow early discontinuation of corticosteroids in patients unlikely to respond.

• If contraindications to corticosteroids are present, use of pentoxifylline is an efficient alternative to improve patients’ outcome by reducing occurrence of hepatorenal syndrome.

• Use of N-acetylcysteine in conjunction with corticosteroids has shown promising results with respect to 1-month survival and 6-month occurrence of hepatorenal syndrome.

• For a strictly selected subset of patients with severe AH and no response to corticosteroids, early liver transplantation is valid as a definitive therapeutic option.

Notes