Alcoholic hepatitis

1. Alcoholic hepatitis Hospitalist Best Practice J Rush Pierce Jr, MD, MPH Lenny Noronha, MD September 11, 2013

2. Disclosures • Financial: none • Affiliations/biases • I drink alcohol • I have a close relative with alcoholism • Evidence should inform our thinking Hospitalist Best Practice: Alcoholic hepatitis

3. Roadmap for today • Describe case • Review recommended evaluation & treatment • Review the role of MELD and Maddrey’s discriminant calculations • Review the literature regarding treatment • Discuss discharge criteria • Review the role of palliative care Hospitalist Best Practice: Alcoholic hepatitis

4. Learning Objectives • List diagnostic criteria for alcoholic hepatitis. • Describe how to use an on-line calculator to predict prognosis and treatment for patients with alcoholic hepatitis. • List recommended treatments for alcoholic hepatitis. Hospitalist Best Practice: Alcoholic hepatitis

5. Case • A 53 year-old man with a long history of daily alcohol use presents with one week of jaundice. BP = 95/60 mm Hg, P = 105/minute, and T = 38.0C. Exam discloses icterus, ascites, and an enlarged, tender liver. Bilirubin = 9 mg/dl, AST = 250 IU/dl, ALT = 115 IU/dl, prothromin time = 22 secs, INR 2.7, creatinine = 0.9 mg/dL, WBC = 15,000/cu mm with 70% neutrophils. How should he be treated? Hospitalist Best Practice: Alcoholic hepatitis

6. Questions you might have • What is his diagnosis? • What evaluation should he have? • What is his prognosis? • How should he be treated? • Do we need to call GI? • How do we monitor his progress? • When can he leave the hospital? Hospitalist Best Practice: Alcoholic hepatitis

7. What is his diagnosis? • Regular, heavy alcohol consumption can be associated with a variety of forms of liver disease, including fatty liver, inflammation, hepatic fibrosis and cirrhosis. • The term alcoholic hepatitis describes a more severe form of alcohol-related liver disease associated with significant short-term mortality. Hospitalist Best Practice: Alcoholic hepatitis

8. Typical clinical and laboratory features of alcoholic hepatitis Hospitalist Best Practice: Alcoholic hepatitis

9. What evaluation should he have? • Confirm the diagnosis • Predict prognosis with MELD and Maddrey’s • Infectious work-up • ordering blood and urine cultures • chest x-ray • paracentesis to exclude SBP Hospitalist Best Practice: Alcoholic hepatitis

10. Common scoring systems used in management of alcoholic hepatitis Hospitalist Best Practice: Alcoholic hepatitis

11. How should he be treated? Hospitalist Best Practice: Alcoholic hepatitis

12. Nutrition • Enteral nutritional support was shown in a multicenter observational study to be associated with reduced infectious complications and improved one year mortality • ACG recommends 35 – 40 kcal/kg per day and protein intake 1.2 – 1.5g/kg per day. In the average 70 kg patient this is 2,450 – 2,800 kcal/day Hospitalist Best Practice: Alcoholic hepatitis

13. Corticosteroids • Recommended by ACG for Maddrey’s > 32 • Cochrane 2008 review • 15 trials with 721 randomized patients • No overall mortality reduction • Mortality reduced w/Maddrey’s > 32 & HE • Another meta-analysis demonstrated a mortality benefit when the largest studies with 221 patients Maddrey’s >32 were analyzed separately Hospitalist Best Practice: Alcoholic hepatitis

14. Corticosteroids • Prednisolone is preferred over prednisone because it is the active drug. • Concerns include hyperglycemia and increased risk of infection. • Contraindications • active infection • gastrointestinal bleeding • acute pancreatitis • renal failure. Hospitalist Best Practice: Alcoholic hepatitis

15. Pentoxifylline • Recommended by ACG if corticosteroids are contraindicated • A 2008 double-blind, placebo controlled trial (n=101) demonstrated decreased 28-day mortality (24.6% vs. 46% receiving placebo) • Cochrane review of all studies concluded that no firm conclusions could be drawn • Small randomized trial (n= 68) showed pentoxifylline superior to prednisolone Hospitalist Best Practice: Alcoholic hepatitis

16. Pentoxifylline • Can be prescribed to patients who have contraindications to corticosteroid use • Dose =400 mg TID for four weeks. • Common side effects are nausea & vomiting • Cannot be administered by NG tube • Should not be used in patients with recent cerebral or retinal hemorrhage. Hospitalist Best Practice: Alcoholic hepatitis

17. DC Med Costs Hospitalist Best Practice: Alcoholic hepatitis

18. Prognosis • Case patient MELD = 26 • Confers 43% - 3 month mortality • Higher if HE or ascites present • High probability to have cirrhosis if he does survive episode of AAH • How should you tell this to patient/family? • What considerations follow in this regard? Hospitalist Best Practice: Alcoholic hepatitis

19. Lille Model Louvet. Hepatology 2007;45:1348 Hospitalist Best Practice: Alcoholic hepatitis

20. Alcoholic liver disease: proposed recommendations for the American College of Gastroenterology Arthur J McCullough and J F Barry O' Connor, Am J Gastr, 1998, 93, 2022-2036. Hospitalist Best Practice: Alcoholic hepatitis

21. Brief Report on UNMH ‘10-’12 Total 467 pts 107 Readmissions Hospitalist Best Practice: Alcoholic hepatitis

22. UNMH AAH ‘10-’12 cont’d • 33 initially adm to MICU • 143 spent time in MICU during admission • Median age 45 • 49 died in hospital • Another 33 reported deaths within 90 days of dc Hospitalist Best Practice: Alcoholic hepatitis

23. UNMH AAH ‘10-’12 Dispo* *based on dc order Hospitalist Best Practice: Alcoholic hepatitis

24. Great reasons to consult Palliative • High mortality condition in young people • Assess understanding of diagnosis/prognosis • Family support • Reinforce your team’s communication (i.e. NG feeds, transplant candidacy, DC) • Support your team • Continuity for pt during long hospitalization • Ward team handoff/ICU transfer Hospitalist Best Practice: Alcoholic hepatitis

25. Early Consultation Preferred! • All patients c AAH, DF > 32 • Please consult as soon as diagnosis suspected • Time to establish rapport Hospitalist Best Practice: Alcoholic hepatitis

26. Palliative Care Consultation • Goals of Care • Advance Care Planning • Describe dispo options (i.e. SNF, NH, home) • ICU transfer, rehospitalization? • Surrogate decision maker • Documentation • Guidance to clarify wishes • Code status • Patient advocacy • Assess spiritual care needs Hospitalist Best Practice: Alcoholic hepatitis

27. Discharge considerations • No clinical trials have studied optimal timing of discharge. Expert opinion based on clinical experience recommends that patients be kept in the hospital until they are eating, signs of alcohol withdrawal and encephalopathy are absent, and bilirubin is less than 10 mg/dl • Attention to abstinence from EtOH is paramount Hospitalist Best Practice: Alcoholic hepatitis

28. Alcoholic hepatitis - approach • Determine that pt fits the clinical picture • Admit and cessation of alcohol • Order folate, thiamine, MVI, and vitamin K. • Add a note about potential withdrawal to hand-off report. • Order an infectious work-up (blood and urine cultures, CXR, and paracentesis). Hospitalist Best Practice: Alcoholic hepatitis

29. Alcoholic hepatitis - approach • Dietary consult for calorie counts, importance of > 2,500 cals/day. • Consider tube feedings if not meeting goal • Determine Maddrey’s and MELD scores • Order prednisolone 40 mg daily; if actively bleeding or infected, Trental 400 mg TID • Determine Lille score treatment day 7 • Discuss code status and end-of life issues • Consider GI consult Hospitalist Best Practice: Alcoholic hepatitis

30. Alcoholic hepatitis – areas of possible consensus • Use of NG feedings for nutrition • When to call GI • When to call palliative care • Evaluation of afebrile leukocytosis • Discharge criteria Hospitalist Best Practice: Alcoholic hepatitis