Alcoholic hepatitis

Question: A known 55 year old alcoholic presents with the following LFT: AST 211, ALT 79, AP 98, Tbili 12.3 (Dbili 9.0).  Seems like a textbook case of alcoholic hepatitis.  INR is 3.  You calculate a discriminant function (DF) of 33.  Which of the following clinical parameters is not a relative contraindication to starting prednisolone 40 mg QD?

A. GI bleeding

B. acute kidney injury

C. ibuprofen use

D. urinary tract infection

Answer: When the Maddrey score (ie. discriminant function) is > 32, steroids are indicated for the treatment of alcoholic hepatitis.  This is, of course, in addition to the other mainstay of treatment: nutrition!  A full course of steroids 40 mg QD lasts for one month, but can be discontinued after 7 days if there is no improvement in the bilirubin.

Remember, there is no window period to begin steroids; it doesn’t matter if they are started on day 1 or any day thereafter.  That said, you often have to rule out certain things before starting steroids, such as infections, bleeding and renal injury.  These are the relative contraindications.  Ibuprofen use is not a contraindication, but you must be aware of the synergistic effect on peptic ulcer disease (relative risk is > 10 X when ibuprofen is added to prednisone).  I’d start a PPI in such cases.

For an interesting discussion about steroids for alcoholic hepatitis (Journ of Hepatol.), click on the link here: Steroids for Alcoholic Hepatitis

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