When are corticosteroids used in alcoholic hepatitis, and what are the cautions?

Clinical relevance. Reserving steroids for severe disease without contraindications, and checking the Lille response, optimises benefit and safety.

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Corticosteroids in alcoholic hepatitis

Steroids are the main specific pharmacological treatment for severe alcoholic hepatitis.

Indication

• Severe alcoholic hepatitis - e.g. Maddrey discriminant function greater than 32, or higher MELD scores (benefit greatest at MELD ~25-39).
• They improve short-term (30-day) survival.

Cautions/contraindications

• Avoid with active gastrointestinal bleeding, active infection, significant renal impairment (e.g. creatinine over ~175 micromol/L).
• Infection must be excluded or treated concurrently.

Adjuncts and monitoring

• N-acetylcysteine may add short-term benefit when combined with steroids.
• Lille score at day 7 assesses response - a poor response means steroids can be stopped.