Alexandre Louvet1, Mark R Thursz2, Dong Joon Kim3, Julien Labreuche4, Stephen R Atkinson2, Sandeep Singh Sidhu5, John G O'Grady6, Evangelos Akriviadis7, Emmanouil Sinakos7, Robert L Carithers8, Marie-José Ramond9, Willis C Maddrey10, Timothy R Morgan11, Alain Duhamel4, Philippe Mathurin12. 1. Service des maladies de l'appareil digestif, CHU Lille, Université de Lille and INSERM U995, Lille, France. 2. Department of Hepatology, Imperial College, Norfolk Place, London, United Kingdom. 3. Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea. 4. Université de Lille, CHU de Lille, EA 2694, Lille, France. 5. Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. 6. Institute of Liver Studies, King's College Hospital, Denmark Hill, London, United Kingdom. 7. 4th Department of Internal Medicine, Aristotle University of Thessaloniki, Greece. 8. Department of Medicine, Seattle, Washington. 9. Hôpital Beaujon, Clichy, France. 10. Department of Medicine, University of Texas, Southwestern Medical Center, Dallas, Texas. 11. Gastroenterology Section, Veterans Affairs Long Beach Healthcare System, Long Beach, California. 12. Service des maladies de l'appareil digestif, CHU Lille, Université de Lille and INSERM U995, Lille, France. Electronic address: philippe.mathurin@chru-lille.fr.
Abstract
BACKGROUND & AIMS: We performed a meta-analysis of individual patient data from 11 randomized controlled trials comparing corticosteroids, pentoxifylline, or their combination in patients with severe alcoholic hepatitis. We compared the effects of the treatments on survival for 28 days or 6 months, and response to treatment based on the Lille model. METHODS: We searched PubMed for randomized controlled trials of pharmacologic therapy for severe alcoholic hepatitis. Our final analysis comprised 11 studies, of 2111 patients. We performed 4 meta-analyses of the effects of corticosteroids vs placebo or control, corticosteroids vs pentoxifylline, corticosteroids and pentoxifylline vs corticosteroids and placebo or control, and pentoxifylline vs placebo. In each meta-analysis, the effect of treatment on the primary outcome (overall survival at 28 days, defined as the period from the first day of assigned treatment to 28 days) was estimated using a Cox proportional hazards regression model, including trials as random effect. RESULTS: Corticosteroid treatment significantly decreased risk of death within 28 days compared with controls (hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.48-0.86) or to pentoxifylline (HR 0.64; 95% CI 0.43-0.95). In multiple-imputation and complete case analyses, the effect of corticosteroids compared with controls remained significant. When we compared corticosteroids vs pentoxifylline, the corticosteroid effect remained significant in the complete case analysis (HR 0.66; P = .04) but not in multiple-imputation analysis (HR 0.71; P = .08). There was no difference in 28-day mortality when patients were given a combination of corticosteroids and pentoxifylline vs corticosteroids alone or between patients given pentoxifylline vs control. In our analysis of secondary outcomes, we found no significant differences in 6-month mortality when any treatments or controls were compared. Corticosteroids were significantly associated with increased response to therapy compared with controls (relative risk 1.24; 95% CI 1.10-1.41) or pentoxifylline (relative risk 1.43; 95% CI 1.20-1.68). We found no difference in response to therapy between patients given a combination of corticosteroids and pentoxifylline vs corticosteroids alone or pentoxifylline vs controls. CONCLUSIONS: In a meta-analysis of 4 controlled trials, we found corticosteroid use to reduce risk of death within 28 days of treatment, but not in the following 6 months. This loss of efficacy over time indicates a need for new therapeutic strategies to improve medium-term outcomes.
BACKGROUND & AIMS: We performed a meta-analysis of individual patient data from 11 randomized controlled trials comparing corticosteroids, pentoxifylline, or their combination in patients with severe alcoholic hepatitis. We compared the effects of the treatments on survival for 28 days or 6 months, and response to treatment based on the Lille model. METHODS: We searched PubMed for randomized controlled trials of pharmacologic therapy for severe alcoholic hepatitis. Our final analysis comprised 11 studies, of 2111 patients. We performed 4 meta-analyses of the effects of corticosteroids vs placebo or control, corticosteroids vs pentoxifylline, corticosteroids and pentoxifylline vs corticosteroids and placebo or control, and pentoxifylline vs placebo. In each meta-analysis, the effect of treatment on the primary outcome (overall survival at 28 days, defined as the period from the first day of assigned treatment to 28 days) was estimated using a Cox proportional hazards regression model, including trials as random effect. RESULTS: Corticosteroid treatment significantly decreased risk of death within 28 days compared with controls (hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.48-0.86) or to pentoxifylline (HR 0.64; 95% CI 0.43-0.95). In multiple-imputation and complete case analyses, the effect of corticosteroids compared with controls remained significant. When we compared corticosteroids vs pentoxifylline, the corticosteroid effect remained significant in the complete case analysis (HR 0.66; P = .04) but not in multiple-imputation analysis (HR 0.71; P = .08). There was no difference in 28-day mortality when patients were given a combination of corticosteroids and pentoxifylline vs corticosteroids alone or between patients given pentoxifylline vs control. In our analysis of secondary outcomes, we found no significant differences in 6-month mortality when any treatments or controls were compared. Corticosteroids were significantly associated with increased response to therapy compared with controls (relative risk 1.24; 95% CI 1.10-1.41) or pentoxifylline (relative risk 1.43; 95% CI 1.20-1.68). We found no difference in response to therapy between patients given a combination of corticosteroids and pentoxifylline vs corticosteroids alone or pentoxifylline vs controls. CONCLUSIONS: In a meta-analysis of 4 controlled trials, we found corticosteroid use to reduce risk of death within 28 days of treatment, but not in the following 6 months. This loss of efficacy over time indicates a need for new therapeutic strategies to improve medium-term outcomes.
Authors: Juan P Arab; Tejasav S Sehrawat; Douglas A Simonetto; Vikas K Verma; Dechun Feng; Tom Tang; Kevin Dreyer; Xiaoqiang Yan; William L Daley; Arun Sanyal; Naga Chalasani; Svetlana Radaeva; Liu Yang; Hugo Vargas; Mauricio Ibacache; Bin Gao; Gregory J Gores; Harmeet Malhi; Patrick S Kamath; Vijay H Shah Journal: Hepatology Date: 2020-04-27 Impact factor: 17.425