A 42-year-old man with heavy alcohol use presents with 2 weeks of jaundice and tender hepatomegaly. Bilirubin is 12 mg/dL, AST 140 U/L, ALT 60 U/L, INR 2.0 (control INR 1.0). There is no encephalopathy and no evidence of infection. What is the most appropriate next step?
- A Start pentoxifylline 400 mg three times daily
- B Start prednisolone 40 mg daily ✓
- C Urgent transjugular liver biopsy before any therapy
- D Abstinence counseling alone with weekly review
Correct answer: B. Start prednisolone 40 mg daily
Explanation
The Maddrey discriminant function is 4.6 times the prothrombin time prolongation in seconds plus bilirubin: 4.6 times 6 equals 27.6, plus 12 gives 39.6, well above the threshold of 32 that predicts high short-term mortality. Prednisolone 40 mg daily improves survival in severe alcoholic hepatitis. Pentoxifylline failed to show benefit over placebo in modern trials and is no longer preferred.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.