[Acute alcoholic hepatitis: treatments].
CONCLUSIONS
Acute alcoholic hepatitis (AAH) is a severe form of alcohol-related liver disease with a high short-term mortality that can reach 50%. Long-term outcome depends on definitive weaning from alcohol and the development of cirrhosis.
Abstention from alcohol is the number one therapeutic measure required for treating AAH. Abstention must be total and definitive.
The pathogenic mechanisms involved in AAH have led to close assessment of numerous treatment protocols. Thirty-three randomized trials have evaluated drug treatments based on various strategies: antiinflammatory action using corticosteroids or colchicine; reduction of the hypermetabolism using propylthiouracil; hepatoprotective effect against oxidative stress using cyanidalol, alpha lipoid acid, silymarine, amlopidine, malotilate; vasodilatation to improve oxygenation of the centrolublular region using a calcium channel inhibitor, amlopidine; increased liver regeneration using anabolism steroids, intravenous perfusion combining insulin and glucagon; antifibrosis action using colchicine, D penicillamine; improved microcirculation due to increased deformability of the red cells and inhibition of TNF-alpha using pentoxifyllin. Eleven therapeutic trials have investigated the effect of parenteral or enteral artificial nutrition.
Among all these strategies, the only one with a proven efficacy is corticosteroid therapy. Four trials have demonstrated the effect of corticosteroid therapy on short-term survival and 3 of the 4 meta-analyses devoted to the topic have demonstrated the usefulness of corticosteroid therapy in severe forms defined by a Maddrey index > or = 32: bilirubin in mumol per liter/17 + 4.6 (patient's PT in seconds--control PT in seconds) and the presence or not of encephalopathy. The gold standard treatment for severe AAH is oral prednisolone 40 mg/d for 1 month (excluding contraindications).


CONCLUSIONS
Despite the effect of corticosteroid therapy, mortality at 2 months in severe AAH is still about 30%. Recent experimental data suggest that monoclonal anti-TNF alpha antibodies could be useful.
Naveau
S
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Service d'Hépato-Gastroentérologie, Hôpital Antoine Béclère, 157, rue de la Porte de Trivaux, F 92141 Clamart. sylvie.naveau@abc.ap-hop-paris.fr
D000208:Acute Disease; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000428:Alcohol Drinking; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D006519:Hepatitis, Alcoholic / Q000188:drug therapy* / Q000473:pathology; D006801:Humans; D011379:Prognosis; D014409:Tumor Necrosis Factor-alpha / Q000276:immunology
D000305:Adrenal Cortex Hormones; D000911:Antibodies, Monoclonal; D014409:Tumor Necrosis Factor-alpha