A 52-year-old man with chronic alcohol use presents with jaundice, hepatomegaly, and elevated transaminases (ALT 180 U/L, AST 240 U/L). Liver biopsy shows hepatocyte ballooning, Mallory–Denk bodies, and neutrophilic infiltration consistent with acute alcoholic hepatitis. Which drug is the first-line treatment to prevent progression to irreversible liver injury (cirrhosis)?

## First-Line Management of Acute Alcoholic Hepatitis **Key Point:** Prednisolone (or methylprednisolone) is the first-line pharmacological agent for moderate-to-severe acute alcoholic hepatitis (AAH) in patients without contraindications. ### Mechanism of Benefit Cortisone reduces hepatic inflammation and neutrophilic infiltration, thereby limiting hepatocyte necrosis and preventing progression from reversible to irreversible injury. It is particularly effective in early AAH when hepatocyte damage is still potentially reversible. ### Dosing & Duration - Standard dose: **Prednisolone 40 mg daily** (or methylprednisolone 32 mg IV daily) for 28 days, then taper - Efficacy is best demonstrated in patients with **Maddrey discriminant function (DF) ≥ 32** or MELD score ≥ 21 ### Selection Criteria | Criterion | Prednisolone Indicated? | |-----------|------------------------| | Moderate–severe AAH (DF ≥ 32) | Yes | | Hepatic encephalopathy present | Relative contraindication | | Active infection (SBP, pneumonia) | Contraindicated | | GI bleeding | Contraindicated | | Renal failure (Cr > 2.5 mg/dL) | Relative contraindication | **High-Yield:** Prednisolone improves 28-day and 6-month survival in severe AAH by halting the reversible phase of hepatocyte injury. ### Adjunctive Measures - Alcohol cessation counselling (most important) - Nutritional support and thiamine supplementation - Management of complications (ascites, encephalopathy) [cite:Robbins 10e Ch 18]