The STOPAH trial was a large, multicenter randomized controlled trial that compared prednisolone, pentoxifylline, both, or placebo in over 1,000 patients with severe alcoholic hepatitis. It found that neither prednisolone nor pentoxifylline reduced all-cause mortality at 28 days, the primary outcome. Prednisolone showed a non-significant mortality benefit at 28 days but no benefit at 90 days or 1 year, and was associated with increased infections. The trial demonstrated that neither medication improves short-term survival in severe alcoholic hepatitis.

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