Stratification and selection of therapies to improve survival in severe alcoholic hepatitis

Abstract

Severe alcoholic hepatitis (SAH) is associated with high short-term mortality. The SAH population exhibits extreme heterogeneity in disease severity, clinical presentation, decompensations, and outcomes. Nonetheless, improving outcomes and preventing adverse events is a major challenge when selecting an appropriate treatment for alcoholic hepatitis. Currently, steroids are the standard of care for SAH with Maddrey’s discriminant function > 32 and model for end stage liver disease > 20; however, they have limited usage due to ineligibility in approximately two-third of such patients. Approximately 25% of patients do not respond to steroids and require alternative therapies. An array of evolving therapies, such as granulocyte colony-stimulating factors, plasma exchange, fecal microbiota transplantation, antibiotics, anti-cytokine therapies, and N-acetylcysteine, showing variable success, are emerging. Hence, it is also crucial to select appropriate therapy. The present review discusses the standard of care, the existing therapies, risk stratification for outcomes, and the selection of appropriate therapy to improve survival in SAH patients.

Keywords: Severe alcoholic hepatitis; Steroids; Granulocyte colony stimulating factor; Plasma exchange; Fecal microbiota transplantation

Core Tip: Clinically, severe alcoholic hepatitis (SAH) presents with jaundice, with or without ascites or encephalopathy, and it progresses rapidly. The patient population is heterogeneous and needs to be stratified according to their eligibility for specific therapies. Emerging alternatives or rescue therapies are available for SAH. The decision for the preferred therapy is based on patient profile, clinical experiences, and its side effects profile. This comprehensive review provides insight into the stratification of patients who need specific therapies, with the primary focus on the therapies that improve survival in SAH.