SlideShare a Scribd company logo
STOPAH
OVMC LANDMARK TRIALS SERIES
Thursz MR, et al. "Prednisolone or pentoxifylline for
alcoholic hepatitis". The New England Journal of Medicine.
2015. 372(17):1619-1628.
Steroids or Pentoxifylline for Alcoholic Hepatitis (STOPAH)
BACKGROUND
 Alcoholic hepatitis is a clinical syndrome:
characteristics features include jaundice and
liver failure
 Severity is defined by Maddrey’s discriminant
function (a score of 32 or higher for
discriminant function, threshold used for most
other alcoholic hepatitis trials)
 Prior to the STOPAH study, there were some
trials that showed benefit of prednisolone and
pentoxifylline in patients with alcoholic
hepatitis, but studies were still limited
CLINICAL QUESTION
In patients with severe alcoholic hepatitis (discriminate function >32), does treatment
with prednisolone OR pentoxifylline improve survival?
DESIGN
 Analysis: Intention-to-treat
 Trial Design: Prospective multicenter randomized, double-blind 2-by-2 factorial design trial
 N=1,092 (5,234 screened)
 Placebo-placebo (n=272)
 Prednisolone-placebo (n=274)
 Pentoxifylline-placebo (n=273)
 Prednisolone-pentoxifylline (n=273)
 Setting: 65 hospitals across the United Kingdom
 Follow-up: 12 months (primary outcome at 28 days)
 Primary outcome: All-cause mortality at 28 days
POPULATION
Inclusion Criteria
 Age ≥18
 Clinical diagnosis of alcoholic hepatitis
 Average alcohol consumption of:
 >80 g/day for males
 >60 g/day for females
 Serum bilirubin >80 μmol/L (4.7 mg/dL)
 Maddrey's discriminant function ≥32
Exclusion Criteria
 Jaundice for >3 months
 Cessation of alcohol consumption >2 months
prior to randomization
 Other causes of liver disease
 Serum AST >500 IU/L or ALT >300 IU/L
 Development of renal failure, active GI
bleeding, untreated sepsis or requirement of
inotrope support, unless it becomes stable in
the first week of admission
INTERVENTIONS
 Participants were randomized to a group:
 Placebo-placebo
 Prednisolone-placebo
 Pentoxifylline-placebo
 Prednisolone-pentoxifylline
 Medications doses:
 Prednisone 40 mg daily
 Pentoxifylline 400 mg TID
 Study medications were continued for 28 days
CRITICISMS/LIMITATIONS/FUNDING
 Lower mortality rates in STOPAH compared to other similarly designed trials
 Likely attributable to:
 Participants were younger and rate of encephalopathy lower (both of which influence mortality)
 Lower incidence of AKI and infections
 Liver biopsy for histologic confirmation was not performed so misdiagnosis of alcoholic
steatohepatitis could occur
 Alcohol consumption data difficult to collect
 No taper in the prednisolone may have resulted in harm to the patients upon medication
withdrawal
FUNDING
 National Institute for Health Research (NIHR) Health Technology Assessment program
BOTTOM LINE
Among patients with severe alcoholic
hepatitis, NEITHER prednisolone nor
pentoxifylline reduces all-cause mortality at
28 days.
Prednisolone was associated with a non-
significant mortality benefit at 28 days but
no benefit at 90 days or 1 year. Further use
was associated with increased infections
BOARD-LIKE QUESTION
29 yo alcoholic male is evaluated for 6month
history of progressive jaundice and weight loss.
Patient’s fiancé says after being terminated from
his job, he started drink 2 packs of beer a day. He
watches TV all day and often does not eat
regular meals.
Physical exam:
T 37, HR 80, BP 108/54, RR 16. BMI 18.
Gen: NAD, thin, muscle wasting, jaundice
Abdomen: B+, tender in RUQ, hepatomegaly
noted
Neuro: confused, A&Ox2 asterixis
Labs:
Hg 11, MCV 77, Ferritin 5
ALT 140, AST 310, Alk phos 135, Albumin 2, T bili
3
FOBT negative
What is the first line treatment for this patient?
A. Oral prednisone
B. Oral pentoxifylline
C. Gluten free diet
D. Refer to GI for treatment of hepatitis
E. Advise alcohol cessation
BOARD-LIKE QUESTION
ANSWER
What is the first line treatment for this patient?
A. Oral prednisone
B. Oral pentoxifylline
C. Gluten free diet
D. Refer to GI for treatment of hepatitis
E. Advise alcohol cessation
Educational Objective:
Identify patients with alcoholic hepatitis and
calculate MDF (Maddrey discriminant function)
Key Point:
MDF = 4.6 (prothrombin time [s] – control prothrombin time
[s]) + total bilirubin (mg/dL)
Patients with hepatic encephalopathy or MDF score of 32 or
greater have high risk of death and warrant treatment with
Prednisone (1st line) or Pentoxifylline (2nd line)
- Prednisone is 1st line and contraindicated in infection,
variceal hemorrhage, or AKI. D/C after day 7 if serum
bilirubin does not improve
- Changing therapy to pentoxifylline thereafter is not
beneficial.
REFERENCES
 Thursz MR, et al. "Prednisolone or pentoxifylline
for alcoholic hepatitis". The New England
Journal of Medicine. 2015. 372(17):1619-1628.
 Brain, P. STOPAH.
https://www.wikijournalclub.org/wiki/STOPAH

More Related Content

What's hot

SALT-E 2
SALT-E 2SALT-E 2
SALT-E 3
SALT-E 3SALT-E 3
CORTICUS
CORTICUSCORTICUS
ATN
ATNATN
CYCLOPS
CYCLOPSCYCLOPS
ACT
ACTACT
GI Bleed
GI BleedGI Bleed
COLONPREV
COLONPREVCOLONPREV
COLONPREV
Isabella Nga Lai
 
Riociguat for the treatment of pah
Riociguat for the treatment of pahRiociguat for the treatment of pah
Riociguat for the treatment of pah
Vishwanath Hesarur
 
RABBIT 2
RABBIT 2RABBIT 2
SALT-E 5
SALT-E 5SALT-E 5
Journal club 26- 5-2017
Journal club 26- 5-2017Journal club 26- 5-2017
Journal club 26- 5-2017
Amit Verma
 
AFFIRM trial JC NOVANT
AFFIRM trial JC NOVANTAFFIRM trial JC NOVANT
AFFIRM trial JC NOVANT
Elmira Darvish
 
ACC 2020 UPDATES
ACC 2020 UPDATESACC 2020 UPDATES
ACC 2020 UPDATES
Praveen Nagula
 
Drugs for CTEPH - studi farmacologici
Drugs for CTEPH - studi farmacologiciDrugs for CTEPH - studi farmacologici
Drugs for CTEPH - studi farmacologici
CTEPH
 
Updated and Overview of HF Trials in ESC 2020
Updated and Overview of HF Trials in ESC 2020Updated and Overview of HF Trials in ESC 2020
Updated and Overview of HF Trials in ESC 2020
Han Naung Tun
 
Effect of pci on long term survival in patients
Effect of pci on long term survival in patientsEffect of pci on long term survival in patients
Effect of pci on long term survival in patients
Monish Hassan
 
BEST OF ESC 2020
BEST OF ESC 2020BEST OF ESC 2020
BEST OF ESC 2020
Praveen Nagula
 
BCC4: Michael Parr on ICU - Surviving Trauma Guidelines
BCC4: Michael Parr on ICU - Surviving Trauma GuidelinesBCC4: Michael Parr on ICU - Surviving Trauma Guidelines
BCC4: Michael Parr on ICU - Surviving Trauma Guidelines
SMACC Conference
 
AZILSARTAN - CILNIDIPINE COMBINATION - The new frontier in hypertension manag...
AZILSARTAN - CILNIDIPINE COMBINATION - The new frontier in hypertension manag...AZILSARTAN - CILNIDIPINE COMBINATION - The new frontier in hypertension manag...
AZILSARTAN - CILNIDIPINE COMBINATION - The new frontier in hypertension manag...
Praveen Nagula
 

What's hot (20)

SALT-E 2
SALT-E 2SALT-E 2
SALT-E 2
 
SALT-E 3
SALT-E 3SALT-E 3
SALT-E 3
 
CORTICUS
CORTICUSCORTICUS
CORTICUS
 
ATN
ATNATN
ATN
 
CYCLOPS
CYCLOPSCYCLOPS
CYCLOPS
 
ACT
ACTACT
ACT
 
GI Bleed
GI BleedGI Bleed
GI Bleed
 
COLONPREV
COLONPREVCOLONPREV
COLONPREV
 
Riociguat for the treatment of pah
Riociguat for the treatment of pahRiociguat for the treatment of pah
Riociguat for the treatment of pah
 
RABBIT 2
RABBIT 2RABBIT 2
RABBIT 2
 
SALT-E 5
SALT-E 5SALT-E 5
SALT-E 5
 
Journal club 26- 5-2017
Journal club 26- 5-2017Journal club 26- 5-2017
Journal club 26- 5-2017
 
AFFIRM trial JC NOVANT
AFFIRM trial JC NOVANTAFFIRM trial JC NOVANT
AFFIRM trial JC NOVANT
 
ACC 2020 UPDATES
ACC 2020 UPDATESACC 2020 UPDATES
ACC 2020 UPDATES
 
Drugs for CTEPH - studi farmacologici
Drugs for CTEPH - studi farmacologiciDrugs for CTEPH - studi farmacologici
Drugs for CTEPH - studi farmacologici
 
Updated and Overview of HF Trials in ESC 2020
Updated and Overview of HF Trials in ESC 2020Updated and Overview of HF Trials in ESC 2020
Updated and Overview of HF Trials in ESC 2020
 
Effect of pci on long term survival in patients
Effect of pci on long term survival in patientsEffect of pci on long term survival in patients
Effect of pci on long term survival in patients
 
BEST OF ESC 2020
BEST OF ESC 2020BEST OF ESC 2020
BEST OF ESC 2020
 
BCC4: Michael Parr on ICU - Surviving Trauma Guidelines
BCC4: Michael Parr on ICU - Surviving Trauma GuidelinesBCC4: Michael Parr on ICU - Surviving Trauma Guidelines
BCC4: Michael Parr on ICU - Surviving Trauma Guidelines
 
AZILSARTAN - CILNIDIPINE COMBINATION - The new frontier in hypertension manag...
AZILSARTAN - CILNIDIPINE COMBINATION - The new frontier in hypertension manag...AZILSARTAN - CILNIDIPINE COMBINATION - The new frontier in hypertension manag...
AZILSARTAN - CILNIDIPINE COMBINATION - The new frontier in hypertension manag...
 

Viewers also liked

Fidaxomicin in cdiff
Fidaxomicin in cdiffFidaxomicin in cdiff
Fidaxomicin in cdiff
Isabella Nga Lai
 
Zinplava
ZinplavaZinplava
Zinplava
jkkmjithin
 
Agroecologia
AgroecologiaAgroecologia
Ppt sociopolitica
Ppt sociopoliticaPpt sociopolitica
Ppt sociopolitica
Ernesto Antonio
 
Aterros sanitarios apostila
Aterros sanitarios apostilaAterros sanitarios apostila
Aterros sanitarios apostila
Walter Neto
 
Corrossion focus on polarization
Corrossion focus on polarizationCorrossion focus on polarization
Corrossion focus on polarization
sruthi Sudhakar
 
Capitulo1
Capitulo1Capitulo1
Capitulo1
ABIGAIL RUIZ
 
CONTOH BLUE PRINT DAN RUMUS EXCEL VALIDITAS
CONTOH BLUE PRINT DAN RUMUS EXCEL VALIDITAS CONTOH BLUE PRINT DAN RUMUS EXCEL VALIDITAS
CONTOH BLUE PRINT DAN RUMUS EXCEL VALIDITAS
Nur Arifaizal Basri
 
Patología: linfoma, sarcoma
Patología: linfoma, sarcomaPatología: linfoma, sarcoma
Patología: linfoma, sarcoma
Ale Osorio
 

Viewers also liked (9)

Fidaxomicin in cdiff
Fidaxomicin in cdiffFidaxomicin in cdiff
Fidaxomicin in cdiff
 
Zinplava
ZinplavaZinplava
Zinplava
 
Agroecologia
AgroecologiaAgroecologia
Agroecologia
 
Ppt sociopolitica
Ppt sociopoliticaPpt sociopolitica
Ppt sociopolitica
 
Aterros sanitarios apostila
Aterros sanitarios apostilaAterros sanitarios apostila
Aterros sanitarios apostila
 
Corrossion focus on polarization
Corrossion focus on polarizationCorrossion focus on polarization
Corrossion focus on polarization
 
Capitulo1
Capitulo1Capitulo1
Capitulo1
 
CONTOH BLUE PRINT DAN RUMUS EXCEL VALIDITAS
CONTOH BLUE PRINT DAN RUMUS EXCEL VALIDITAS CONTOH BLUE PRINT DAN RUMUS EXCEL VALIDITAS
CONTOH BLUE PRINT DAN RUMUS EXCEL VALIDITAS
 
Patología: linfoma, sarcoma
Patología: linfoma, sarcomaPatología: linfoma, sarcoma
Patología: linfoma, sarcoma
 

Similar to STOPAH

ALCOHOLIC hepatitis.pptx
ALCOHOLIC hepatitis.pptxALCOHOLIC hepatitis.pptx
ALCOHOLIC hepatitis.pptx
vishaldattKohir1
 
Thuốc điều trị tăng huyết áp trên bệnh thận đái tháo đường - BS Phạm Văn Bù...
Thuốc điều trị tăng huyết áp trên bệnh thận đái tháo đường - BS Phạm Văn Bù...Thuốc điều trị tăng huyết áp trên bệnh thận đái tháo đường - BS Phạm Văn Bù...
Thuốc điều trị tăng huyết áp trên bệnh thận đái tháo đường - BS Phạm Văn Bù...
cacao83
 
Cdmjc cole4
Cdmjc cole4Cdmjc cole4
Cdmjc cole4
Shaun0479
 
ADVANCES IN PULMONARY HTN TREATMENT
ADVANCES IN PULMONARY HTN TREATMENTADVANCES IN PULMONARY HTN TREATMENT
ADVANCES IN PULMONARY HTN TREATMENT
drrajeevsharma7
 
Fibrosis[1]
Fibrosis[1]Fibrosis[1]
Fibrosis[1]
specialclass
 
Pulmonary hypertension
Pulmonary hypertensionPulmonary hypertension
Pulmonary hypertension
Dr. Rohit Saini
 
Les hépatites auto-immunes - Jean-Charles DUCLOS-VALLEE
Les hépatites auto-immunes - Jean-Charles DUCLOS-VALLEE Les hépatites auto-immunes - Jean-Charles DUCLOS-VALLEE
Les hépatites auto-immunes - Jean-Charles DUCLOS-VALLEE
Centre Hepato-Biliaire / AP-HP Hopital Paul Brousse
 
Advances in treatment of Pulmonary Arterial Hypertension
Advances in treatment of Pulmonary Arterial HypertensionAdvances in treatment of Pulmonary Arterial Hypertension
Advances in treatment of Pulmonary Arterial Hypertension
LPS Institute of Cardiology Kanpur UP India
 
Git Bmj Dyspepsia Mangement.
Git Bmj Dyspepsia Mangement.Git Bmj Dyspepsia Mangement.
Git Bmj Dyspepsia Mangement.
Shaikhani.
 
Hospital Medicine Pearls, VA ACP Meeting 2014
Hospital Medicine Pearls, VA ACP Meeting 2014Hospital Medicine Pearls, VA ACP Meeting 2014
Hospital Medicine Pearls, VA ACP Meeting 2014
Jon Sweet
 
Hospital Medicine Update, VA ACP Meeting 2015
Hospital Medicine Update, VA ACP Meeting 2015Hospital Medicine Update, VA ACP Meeting 2015
Hospital Medicine Update, VA ACP Meeting 2015
Jon Sweet
 
FIGARO-DKD-Presentation.pptx
FIGARO-DKD-Presentation.pptxFIGARO-DKD-Presentation.pptx
FIGARO-DKD-Presentation.pptx
JackJack424700
 
Evidence Based Review CHF
Evidence Based Review CHFEvidence Based Review CHF
Evidence Based Review CHF
mdmendoz
 
Saxagliptin Diabetes DPP4 evidences & Trials
Saxagliptin Diabetes DPP4 evidences & TrialsSaxagliptin Diabetes DPP4 evidences & Trials
Saxagliptin Diabetes DPP4 evidences & Trials
AmitSaha472186
 
Wj Gv15i13
Wj Gv15i13Wj Gv15i13
Wj Gv15i13
guest76921ba
 
Ueda2015 unmet medical needs in dm dr.lobna el-toony
Ueda2015 unmet medical needs in dm dr.lobna el-toonyUeda2015 unmet medical needs in dm dr.lobna el-toony
Ueda2015 unmet medical needs in dm dr.lobna el-toony
ueda2015
 
2014.pptx
2014.pptx2014.pptx
PAH management
PAH managementPAH management
PAH management
Waleed Al Keridy
 
Clinical Case Study
Clinical Case StudyClinical Case Study
Clinical Case Study
Ashley Hamilton
 
Diabetes of stout people
Diabetes of stout peopleDiabetes of stout people
Diabetes of stout people
Usama Ragab
 

Similar to STOPAH (20)

ALCOHOLIC hepatitis.pptx
ALCOHOLIC hepatitis.pptxALCOHOLIC hepatitis.pptx
ALCOHOLIC hepatitis.pptx
 
Thuốc điều trị tăng huyết áp trên bệnh thận đái tháo đường - BS Phạm Văn Bù...
Thuốc điều trị tăng huyết áp trên bệnh thận đái tháo đường - BS Phạm Văn Bù...Thuốc điều trị tăng huyết áp trên bệnh thận đái tháo đường - BS Phạm Văn Bù...
Thuốc điều trị tăng huyết áp trên bệnh thận đái tháo đường - BS Phạm Văn Bù...
 
Cdmjc cole4
Cdmjc cole4Cdmjc cole4
Cdmjc cole4
 
ADVANCES IN PULMONARY HTN TREATMENT
ADVANCES IN PULMONARY HTN TREATMENTADVANCES IN PULMONARY HTN TREATMENT
ADVANCES IN PULMONARY HTN TREATMENT
 
Fibrosis[1]
Fibrosis[1]Fibrosis[1]
Fibrosis[1]
 
Pulmonary hypertension
Pulmonary hypertensionPulmonary hypertension
Pulmonary hypertension
 
Les hépatites auto-immunes - Jean-Charles DUCLOS-VALLEE
Les hépatites auto-immunes - Jean-Charles DUCLOS-VALLEE Les hépatites auto-immunes - Jean-Charles DUCLOS-VALLEE
Les hépatites auto-immunes - Jean-Charles DUCLOS-VALLEE
 
Advances in treatment of Pulmonary Arterial Hypertension
Advances in treatment of Pulmonary Arterial HypertensionAdvances in treatment of Pulmonary Arterial Hypertension
Advances in treatment of Pulmonary Arterial Hypertension
 
Git Bmj Dyspepsia Mangement.
Git Bmj Dyspepsia Mangement.Git Bmj Dyspepsia Mangement.
Git Bmj Dyspepsia Mangement.
 
Hospital Medicine Pearls, VA ACP Meeting 2014
Hospital Medicine Pearls, VA ACP Meeting 2014Hospital Medicine Pearls, VA ACP Meeting 2014
Hospital Medicine Pearls, VA ACP Meeting 2014
 
Hospital Medicine Update, VA ACP Meeting 2015
Hospital Medicine Update, VA ACP Meeting 2015Hospital Medicine Update, VA ACP Meeting 2015
Hospital Medicine Update, VA ACP Meeting 2015
 
FIGARO-DKD-Presentation.pptx
FIGARO-DKD-Presentation.pptxFIGARO-DKD-Presentation.pptx
FIGARO-DKD-Presentation.pptx
 
Evidence Based Review CHF
Evidence Based Review CHFEvidence Based Review CHF
Evidence Based Review CHF
 
Saxagliptin Diabetes DPP4 evidences & Trials
Saxagliptin Diabetes DPP4 evidences & TrialsSaxagliptin Diabetes DPP4 evidences & Trials
Saxagliptin Diabetes DPP4 evidences & Trials
 
Wj Gv15i13
Wj Gv15i13Wj Gv15i13
Wj Gv15i13
 
Ueda2015 unmet medical needs in dm dr.lobna el-toony
Ueda2015 unmet medical needs in dm dr.lobna el-toonyUeda2015 unmet medical needs in dm dr.lobna el-toony
Ueda2015 unmet medical needs in dm dr.lobna el-toony
 
2014.pptx
2014.pptx2014.pptx
2014.pptx
 
PAH management
PAH managementPAH management
PAH management
 
Clinical Case Study
Clinical Case StudyClinical Case Study
Clinical Case Study
 
Diabetes of stout people
Diabetes of stout peopleDiabetes of stout people
Diabetes of stout people
 

Recently uploaded

HYPERTENSION - SLIDE SHARE PRESENTATION.
HYPERTENSION - SLIDE SHARE PRESENTATION.HYPERTENSION - SLIDE SHARE PRESENTATION.
HYPERTENSION - SLIDE SHARE PRESENTATION.
deepaannamalai16
 
The basics of sentences session 7pptx.pptx
The basics of sentences session 7pptx.pptxThe basics of sentences session 7pptx.pptx
The basics of sentences session 7pptx.pptx
heathfieldcps1
 
How Barcodes Can Be Leveraged Within Odoo 17
How Barcodes Can Be Leveraged Within Odoo 17How Barcodes Can Be Leveraged Within Odoo 17
How Barcodes Can Be Leveraged Within Odoo 17
Celine George
 
Pharmaceutics Pharmaceuticals best of brub
Pharmaceutics Pharmaceuticals best of brubPharmaceutics Pharmaceuticals best of brub
Pharmaceutics Pharmaceuticals best of brub
danielkiash986
 
مصحف القراءات العشر أعد أحرف الخلاف سمير بسيوني.pdf
مصحف القراءات العشر   أعد أحرف الخلاف سمير بسيوني.pdfمصحف القراءات العشر   أعد أحرف الخلاف سمير بسيوني.pdf
مصحف القراءات العشر أعد أحرف الخلاف سمير بسيوني.pdf
سمير بسيوني
 
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...
EduSkills OECD
 
Electric Fetus - Record Store Scavenger Hunt
Electric Fetus - Record Store Scavenger HuntElectric Fetus - Record Store Scavenger Hunt
Electric Fetus - Record Store Scavenger Hunt
RamseyBerglund
 
THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...
THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...
THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...
indexPub
 
Mule event processing models | MuleSoft Mysore Meetup #47
Mule event processing models | MuleSoft Mysore Meetup #47Mule event processing models | MuleSoft Mysore Meetup #47
Mule event processing models | MuleSoft Mysore Meetup #47
MysoreMuleSoftMeetup
 
NEWSPAPERS - QUESTION 1 - REVISION POWERPOINT.pptx
NEWSPAPERS - QUESTION 1 - REVISION POWERPOINT.pptxNEWSPAPERS - QUESTION 1 - REVISION POWERPOINT.pptx
NEWSPAPERS - QUESTION 1 - REVISION POWERPOINT.pptx
iammrhaywood
 
Bonku-Babus-Friend by Sathyajith Ray (9)
Bonku-Babus-Friend by Sathyajith Ray  (9)Bonku-Babus-Friend by Sathyajith Ray  (9)
Bonku-Babus-Friend by Sathyajith Ray (9)
nitinpv4ai
 
A Visual Guide to 1 Samuel | A Tale of Two Hearts
A Visual Guide to 1 Samuel | A Tale of Two HeartsA Visual Guide to 1 Samuel | A Tale of Two Hearts
A Visual Guide to 1 Samuel | A Tale of Two Hearts
Steve Thomason
 
Data Structure using C by Dr. K Adisesha .ppsx
Data Structure using C by Dr. K Adisesha .ppsxData Structure using C by Dr. K Adisesha .ppsx
Data Structure using C by Dr. K Adisesha .ppsx
Prof. Dr. K. Adisesha
 
Benner "Expanding Pathways to Publishing Careers"
Benner "Expanding Pathways to Publishing Careers"Benner "Expanding Pathways to Publishing Careers"
Benner "Expanding Pathways to Publishing Careers"
National Information Standards Organization (NISO)
 
What is Digital Literacy? A guest blog from Andy McLaughlin, University of Ab...
What is Digital Literacy? A guest blog from Andy McLaughlin, University of Ab...What is Digital Literacy? A guest blog from Andy McLaughlin, University of Ab...
What is Digital Literacy? A guest blog from Andy McLaughlin, University of Ab...
GeorgeMilliken2
 
Leveraging Generative AI to Drive Nonprofit Innovation
Leveraging Generative AI to Drive Nonprofit InnovationLeveraging Generative AI to Drive Nonprofit Innovation
Leveraging Generative AI to Drive Nonprofit Innovation
TechSoup
 
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) Curriculum
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumPhilippine Edukasyong Pantahanan at Pangkabuhayan (EPP) Curriculum
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) Curriculum
MJDuyan
 
Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...
Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...
Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...
TechSoup
 
How to Predict Vendor Bill Product in Odoo 17
How to Predict Vendor Bill Product in Odoo 17How to Predict Vendor Bill Product in Odoo 17
How to Predict Vendor Bill Product in Odoo 17
Celine George
 
Geography as a Discipline Chapter 1 __ Class 11 Geography NCERT _ Class Notes...
Geography as a Discipline Chapter 1 __ Class 11 Geography NCERT _ Class Notes...Geography as a Discipline Chapter 1 __ Class 11 Geography NCERT _ Class Notes...
Geography as a Discipline Chapter 1 __ Class 11 Geography NCERT _ Class Notes...
ImMuslim
 

Recently uploaded (20)

HYPERTENSION - SLIDE SHARE PRESENTATION.
HYPERTENSION - SLIDE SHARE PRESENTATION.HYPERTENSION - SLIDE SHARE PRESENTATION.
HYPERTENSION - SLIDE SHARE PRESENTATION.
 
The basics of sentences session 7pptx.pptx
The basics of sentences session 7pptx.pptxThe basics of sentences session 7pptx.pptx
The basics of sentences session 7pptx.pptx
 
How Barcodes Can Be Leveraged Within Odoo 17
How Barcodes Can Be Leveraged Within Odoo 17How Barcodes Can Be Leveraged Within Odoo 17
How Barcodes Can Be Leveraged Within Odoo 17
 
Pharmaceutics Pharmaceuticals best of brub
Pharmaceutics Pharmaceuticals best of brubPharmaceutics Pharmaceuticals best of brub
Pharmaceutics Pharmaceuticals best of brub
 
مصحف القراءات العشر أعد أحرف الخلاف سمير بسيوني.pdf
مصحف القراءات العشر   أعد أحرف الخلاف سمير بسيوني.pdfمصحف القراءات العشر   أعد أحرف الخلاف سمير بسيوني.pdf
مصحف القراءات العشر أعد أحرف الخلاف سمير بسيوني.pdf
 
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...
 
Electric Fetus - Record Store Scavenger Hunt
Electric Fetus - Record Store Scavenger HuntElectric Fetus - Record Store Scavenger Hunt
Electric Fetus - Record Store Scavenger Hunt
 
THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...
THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...
THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...
 
Mule event processing models | MuleSoft Mysore Meetup #47
Mule event processing models | MuleSoft Mysore Meetup #47Mule event processing models | MuleSoft Mysore Meetup #47
Mule event processing models | MuleSoft Mysore Meetup #47
 
NEWSPAPERS - QUESTION 1 - REVISION POWERPOINT.pptx
NEWSPAPERS - QUESTION 1 - REVISION POWERPOINT.pptxNEWSPAPERS - QUESTION 1 - REVISION POWERPOINT.pptx
NEWSPAPERS - QUESTION 1 - REVISION POWERPOINT.pptx
 
Bonku-Babus-Friend by Sathyajith Ray (9)
Bonku-Babus-Friend by Sathyajith Ray  (9)Bonku-Babus-Friend by Sathyajith Ray  (9)
Bonku-Babus-Friend by Sathyajith Ray (9)
 
A Visual Guide to 1 Samuel | A Tale of Two Hearts
A Visual Guide to 1 Samuel | A Tale of Two HeartsA Visual Guide to 1 Samuel | A Tale of Two Hearts
A Visual Guide to 1 Samuel | A Tale of Two Hearts
 
Data Structure using C by Dr. K Adisesha .ppsx
Data Structure using C by Dr. K Adisesha .ppsxData Structure using C by Dr. K Adisesha .ppsx
Data Structure using C by Dr. K Adisesha .ppsx
 
Benner "Expanding Pathways to Publishing Careers"
Benner "Expanding Pathways to Publishing Careers"Benner "Expanding Pathways to Publishing Careers"
Benner "Expanding Pathways to Publishing Careers"
 
What is Digital Literacy? A guest blog from Andy McLaughlin, University of Ab...
What is Digital Literacy? A guest blog from Andy McLaughlin, University of Ab...What is Digital Literacy? A guest blog from Andy McLaughlin, University of Ab...
What is Digital Literacy? A guest blog from Andy McLaughlin, University of Ab...
 
Leveraging Generative AI to Drive Nonprofit Innovation
Leveraging Generative AI to Drive Nonprofit InnovationLeveraging Generative AI to Drive Nonprofit Innovation
Leveraging Generative AI to Drive Nonprofit Innovation
 
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) Curriculum
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumPhilippine Edukasyong Pantahanan at Pangkabuhayan (EPP) Curriculum
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) Curriculum
 
Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...
Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...
Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...
 
How to Predict Vendor Bill Product in Odoo 17
How to Predict Vendor Bill Product in Odoo 17How to Predict Vendor Bill Product in Odoo 17
How to Predict Vendor Bill Product in Odoo 17
 
Geography as a Discipline Chapter 1 __ Class 11 Geography NCERT _ Class Notes...
Geography as a Discipline Chapter 1 __ Class 11 Geography NCERT _ Class Notes...Geography as a Discipline Chapter 1 __ Class 11 Geography NCERT _ Class Notes...
Geography as a Discipline Chapter 1 __ Class 11 Geography NCERT _ Class Notes...
 

STOPAH

  • 1. STOPAH OVMC LANDMARK TRIALS SERIES Thursz MR, et al. "Prednisolone or pentoxifylline for alcoholic hepatitis". The New England Journal of Medicine. 2015. 372(17):1619-1628.
  • 2. Steroids or Pentoxifylline for Alcoholic Hepatitis (STOPAH)
  • 3. BACKGROUND  Alcoholic hepatitis is a clinical syndrome: characteristics features include jaundice and liver failure  Severity is defined by Maddrey’s discriminant function (a score of 32 or higher for discriminant function, threshold used for most other alcoholic hepatitis trials)  Prior to the STOPAH study, there were some trials that showed benefit of prednisolone and pentoxifylline in patients with alcoholic hepatitis, but studies were still limited
  • 4. CLINICAL QUESTION In patients with severe alcoholic hepatitis (discriminate function >32), does treatment with prednisolone OR pentoxifylline improve survival?
  • 5. DESIGN  Analysis: Intention-to-treat  Trial Design: Prospective multicenter randomized, double-blind 2-by-2 factorial design trial  N=1,092 (5,234 screened)  Placebo-placebo (n=272)  Prednisolone-placebo (n=274)  Pentoxifylline-placebo (n=273)  Prednisolone-pentoxifylline (n=273)  Setting: 65 hospitals across the United Kingdom  Follow-up: 12 months (primary outcome at 28 days)  Primary outcome: All-cause mortality at 28 days
  • 6. POPULATION Inclusion Criteria  Age ≥18  Clinical diagnosis of alcoholic hepatitis  Average alcohol consumption of:  >80 g/day for males  >60 g/day for females  Serum bilirubin >80 μmol/L (4.7 mg/dL)  Maddrey's discriminant function ≥32 Exclusion Criteria  Jaundice for >3 months  Cessation of alcohol consumption >2 months prior to randomization  Other causes of liver disease  Serum AST >500 IU/L or ALT >300 IU/L  Development of renal failure, active GI bleeding, untreated sepsis or requirement of inotrope support, unless it becomes stable in the first week of admission
  • 7. INTERVENTIONS  Participants were randomized to a group:  Placebo-placebo  Prednisolone-placebo  Pentoxifylline-placebo  Prednisolone-pentoxifylline  Medications doses:  Prednisone 40 mg daily  Pentoxifylline 400 mg TID  Study medications were continued for 28 days
  • 8. CRITICISMS/LIMITATIONS/FUNDING  Lower mortality rates in STOPAH compared to other similarly designed trials  Likely attributable to:  Participants were younger and rate of encephalopathy lower (both of which influence mortality)  Lower incidence of AKI and infections  Liver biopsy for histologic confirmation was not performed so misdiagnosis of alcoholic steatohepatitis could occur  Alcohol consumption data difficult to collect  No taper in the prednisolone may have resulted in harm to the patients upon medication withdrawal FUNDING  National Institute for Health Research (NIHR) Health Technology Assessment program
  • 9. BOTTOM LINE Among patients with severe alcoholic hepatitis, NEITHER prednisolone nor pentoxifylline reduces all-cause mortality at 28 days. Prednisolone was associated with a non- significant mortality benefit at 28 days but no benefit at 90 days or 1 year. Further use was associated with increased infections
  • 10. BOARD-LIKE QUESTION 29 yo alcoholic male is evaluated for 6month history of progressive jaundice and weight loss. Patient’s fiancé says after being terminated from his job, he started drink 2 packs of beer a day. He watches TV all day and often does not eat regular meals. Physical exam: T 37, HR 80, BP 108/54, RR 16. BMI 18. Gen: NAD, thin, muscle wasting, jaundice Abdomen: B+, tender in RUQ, hepatomegaly noted Neuro: confused, A&Ox2 asterixis Labs: Hg 11, MCV 77, Ferritin 5 ALT 140, AST 310, Alk phos 135, Albumin 2, T bili 3 FOBT negative What is the first line treatment for this patient? A. Oral prednisone B. Oral pentoxifylline C. Gluten free diet D. Refer to GI for treatment of hepatitis E. Advise alcohol cessation
  • 11. BOARD-LIKE QUESTION ANSWER What is the first line treatment for this patient? A. Oral prednisone B. Oral pentoxifylline C. Gluten free diet D. Refer to GI for treatment of hepatitis E. Advise alcohol cessation Educational Objective: Identify patients with alcoholic hepatitis and calculate MDF (Maddrey discriminant function) Key Point: MDF = 4.6 (prothrombin time [s] – control prothrombin time [s]) + total bilirubin (mg/dL) Patients with hepatic encephalopathy or MDF score of 32 or greater have high risk of death and warrant treatment with Prednisone (1st line) or Pentoxifylline (2nd line) - Prednisone is 1st line and contraindicated in infection, variceal hemorrhage, or AKI. D/C after day 7 if serum bilirubin does not improve - Changing therapy to pentoxifylline thereafter is not beneficial.
  • 12. REFERENCES  Thursz MR, et al. "Prednisolone or pentoxifylline for alcoholic hepatitis". The New England Journal of Medicine. 2015. 372(17):1619-1628.  Brain, P. STOPAH. https://www.wikijournalclub.org/wiki/STOPAH