Contraindications of steroid treatment in the setting of severe alcohol-associated hepatitis: are they absolute contraindications?

BACKGROUND

Severe alcohol-associated hepatitis (AH) remains a major challenge in clinical practice due to its limited treatment options and high short-term mortality. Although corticosteroids have long been the mainstay of treatment, their use has been declining because of concerns about side effects and contraindications.

AIM: We aimed to summarize the current standards for corticosteroid use in severe AH, with a specific focus on differentiating absolute from relative contraindications.

METHODS

This narrative review integrates evidence from randomized clinical trials, observational cohort studies, and contemporary guideline statements pertaining to corticosteroid therapy in severe alcohol‑associated hepatitis.

RESULTS

The majority of individuals with severe AH present with concomitant complications such as infection, acute kidney injury, or gastrointestinal bleeding. Emerging data indicates that, with the developments in diagnostic methods, treatment strategies, and supportive care, that were previously considered absolute contraindications are now being recognized as relative. Corticosteroid treatment can be administered safely once certain concomitant conditions have been stabilized or resolved. On the other hand, such severe presentations, as identified by markedly elevated Maddrey's discriminant function, MELD score, or acute-on-chronic liver failure (ACLF) grade, determine a poor response to corticosteroid treatment and high risk of complications.

CONCLUSIONS

In the setting of severe AH, while certain conditions require a temporary corticosteroid treatment delay, others necessitate alternative approaches. Individuals with a low likelihood of responding, early liver transplantation, extracorporeal therapy, microbiota-based therapeutics, or palliative care should be considered in the earlier settings.