Alcoholic hepatitis (AH) is an acute hepatic inflammation that causes significant morbidity and mortality. Its pathogenesis is thought of as the end result of the complex interplay between ethanol metabolism, inflammation and innate immunity. 

Pharmacological therapies for AH includes the use of Corticosteroids. They suppress the immune system activated by an enhanced generation of neo-antigens and liver membrane antigens. It also inhibits the production of TNF-α. Current practice guideline recommends glucocorticoid treatment in patients with severe alcoholic hepatitis (mDF > 32) with hepatic encephalopathy while it is contraindicated in those with infection, GI bleeding, acute pancreatitis, or renal failure.

Anti-TNF therapy: Pentoxifylline, a phosphodiesterase inhibitor, has been shown to decrease the transcription of the TNF-α promoter. A study utilizing pentoxifylline in subjects with severe alcoholic hepatitis showed improvement in mortality which was secondary to a concomitant decrease in the incidence of hepatorenal syndrome. Another recent meta-analysis of five trials showed pentoxifylline reduces mortality compared with control.

Another study proved pentoxifylline to be superior to prednisolone for treatment of severe alcoholic hepatitis with a significantly lower MELD score at the end of 28 d of therapy. 

Currently, pentoxifylline s used as an alternative when corticosteroids are contraindicated, while many centers use it as a first-line treatment for severe AH patients.

Patients with alcoholic hepatitis are usually malnourished. Thus nutritional supplement remains necessary.

Current guidelines do not recommend Liver transplantation for patients with alcoholic hepatitis, and 6-month abstinence is usually required. A recent study demonstrated the benefit of early liver transplantation to improve the 6 mo survival rate in patients with severe alcoholic hepatitis not responding to medical therapy. Further, this benefit of early transplantation was maintained through 2 years of follow-up.

Abstinence remains the key to prevent further liver injury and benefits patients at every stage of the disease. Medicines like naltrexone and acamprosate are used to help with abstinence. A study has demonstrated baclofen, an alpha-aminobutyric acid B-receptor agonist, to promote short-term abstinence in a group of actively drinking patients with alcoholic cirrhosis. Generally, treatment of alcohol disorders requires multi-disciplinary approaches.

Source: Chayanupatkul M, Liangpunsakul S. Alcoholic hepatitis: a comprehensive review of pathogenesis and treatment. World J Gastroenterol. 2014;20(20):6279-6286. doi:10.3748/wjg.v20.i20.6279