Glucocorticoids can help in acute severe alcoholic hepatitis

Abstract

Sirs, Recently Rambaldi et al.1 conducted a comprehensive meta-analysis on all trials of glucocorticoids in acute alcoholic hepatitis and found no overall effect on mortality or other complications and an increased rate of adverse events. However, they did find a beneficial effect on mortality (RR 0.37; 95% CI: 0.16–0.86) for objectively severe disease (Maddrey DF ≥32 and/or encephalopathy) from a relatively small sample size of 249 patients. There is another source of data which the authors appear to have not included in their analysis of severe disease, that is the large study by Mendenhall et al.2 for which information of over 100 additional patients with severe disease can be determined from the meta-analysis by Mathurin et al. (Mathurin et al. list one more patient than Rambaldi et al., but this makes no appreciable difference to the results).3 Combining this study with that of Rambaldi et al. (see figure from Rev Man 5.0) gives a similar effect size in 368 severe patients (RR 0.44; 95% CI: 0.23–0.84). This analysis includes two of the three studies identified by Rambaldi et al. as being at low risk of bias, is not affected by correction using the published regression coefficients (for bilirubin and age at baseline) and is robust to excluding small studies. With a relative risk of this magnitude (rather than the 0.80 RR assumed by Rambaldi et al.), there is sufficient ‘information size’ in over 300 patients suggesting that the evidence currently supports the use of glucocorticoids in the treatment of acute severe alcoholic hepatitis. Declaration of personal and funding interests: None.