Novel Therapies in Moderately Severe Acute Alcoholic Hepatitis
Phase: NA
Conditions: Acute Alcoholic Hepatitis
Sponsor: University of Texas Southwestern Medical Center

Official title: Novel Therapies in Moderately Severe Acute Alcoholic 
Hepatitis 
 
 
 
NCT number: NCT01922895 
IRB Approved date: November 16, 2015 

Page 1 of 16 
 
The University of Texas Southwestern Medical Center at Dallas 
Institutional Review Board 
Novel Therapies in Moderately Severe Acute Alcoholic Hepatitis 
1. Study Specific Aims: 
Aim 1: Evaluate the effects of probiotic supplements on improvement in MELD score and gut 
mucosal integrity in patients with MELD < 20. Patients will be randomized to receive daily probiotics 
(Culturelle®: a nutritional supplement containing Lactobacillus Rhamnosus GG, manufactured by 
iHealth, Inc.) for 6 months and standard of care treatment or placebo with standard care (described 
below). Primary outcome will be change in MELD score at 30 days after randomization. Secondary 
outcomes will be measured at 30, 90 and 180 days. These include improvement in MELD score, gut 
mucosal permeability, liver enzymes, serum endotoxin and the levels of TNF and other cytokines 
from baseline; and mortality. 
Aim 2: Document the natural history of moderately severe alcoholic hepatitis. Patients who decline 
randomization will be offered the option of inclusion in the study prospectively for data collection 
purposes and research study procedures. 
Aim 3: Create a data and tissue biorepository. This biorepository will serve as a national resource for 
all studies related to acute alcoholic hepatitis. Our research group will use the samples and share 
with others for future studies on biomarkers for AAH severity/outcome, cost analysis, rationales for 
new therapies, etc. 
2. Background: 
Acute alcoholic hepatitis (AAH) is an important cause of morbidity, mortality and healthcare costs in 
the United States and most Western countries. The 2007 nationwide inpatient sample from the 
Healthcare Cost and Utilization Project reported that 56,809 patients (0.71% of the total) were 
hospitalized with AH
(1). Average hospital costs were $37,769, more than twice the cost of myocardial 
infarction. Length of stay was significantly higher in those who died compared to those who survived 
(9.3 vs. 6.2 days). Total charges (~$85,000) were 2.5-fold higher in those who died than those who 
survived. The 28-day mortality of AAH in Denmark rose from 12 to 15%, and the 84-day mortality 
increased from 14 to 24% between 1999-2008
(2) with 5-year mortality of 56%. These data from 
Denmark are similar to the 1991 VA Cooperative data: 4-year mortality of 42% with AH alone, and 
65% with AH plus cirrhosis
(3). Aggregated mortality of 661 placebo-treated patients from 19 trials 
was 20% at 30 days and 34% at a median of 160 days follow-up
(4). 
Statistics illustrate the grim outcome of AAH despite major advances in critical care and other 
medical interventions over the last 3 decades. While hepatic steatosis develops in the majority of 
heavy drinkers, alcoholic hepatitis and cirrhosis occur in only 20-25% (reviewed in (5)). All patients 
with AAH have a background of hepatic steatosis that represents a consequence of metabolic and 
oxidative stress. The inflammatory nature of alcoholic hepatitis is highlighted clinically by elevation in 
white blood cell count (WBC) and occasionally fever and pathologically by infiltration of the liver with 
neutrophils. A number of studies have implicated the gut flora, in particular gut-derived toxins, as a 
“second hit” in the pathogenesis of acute alcoholic hepatitis and cirrhosis. Endotoxin 
(lipopolysaccharide, LPS) binds to toll-like receptor 4 (TLR4), a receptor that plays a key role in 
initiating release of tumor necrosis factor (TNFα) and other cytokines by activated Kupffer cells in 
experimental models of alcoholic liver injury
(6-8). 

Page 2 of 16 
 
High serum levels of TNFα are associated with the clinical severity of alcoholic hepatitis
(9) and there 
is increased production of TNFα in monocytes isolated from patients with alcoholic hepatitis
(10). Other 
studies have suggested that alcohol increases gut permeability in animal models and in heavy 
drinkers
(11), a potential contributing factor in how endotoxin or other bacterial products reach the liver. 
Endotoxemia occurs frequently in patients with cirrhosis and in those with chronic hepatitis
(12, 13) 
probably due to increased gut bacterial translocation. Furthermore, recent studies reported 
alterations in the gut microbiome in alcohol-fed animals
(14), a finding that could also promote 
increased permeability of the gut mucosa. We hypothesize that impairment of gut mucosal 
integrity is the unifying “second hit” with potential contributing factors including the 
microbiome, nutritional deficiencies and direct effects of alcohol. 
Published data show that several agents are beneficial in short-term treatment of severe AAH, but 
none has proven to impact 6 month mortality when used as monotherapy
(15). Combining therapeutic 
agents that target different pathways while avoiding the risks of infection and hepatorenal syndrome 
may improve mortality particularly in the most severely ill patients with AAH. Furthermore, no 
specific interventions or medications benefit patients with mild to moderate AAH
(14). The proposed 
study will use specific agents to target impairment in gut mucosal integrity in patients with 
moderately severe AAH. The potential benefit is to not only to improve treatment but also to provide 
evidence of the roles of gut mucosal integrity in the pathogenesis of AAH. 
The proposed studies represent the culmination of a planning process involving the members of the 
proposed Executive Committee and other co-investigators. The criteria for selecting the proposed 
treatment included a known safety profile so that a beneficial treatment(s) could be brought forward 
for a phase III clinical trial and/or transform treatment for AAH, a condition for which the current 
treatment paradigm is unsatisfactory. The selection of the medications was based on the 
hypothesis that the syndrome of AAH results from inflammation triggered by gut derived 
endotoxins and other bacterial products as a consequence of increased permeability of the 
gut mucosa. 
The standard of care (nutritional support, alcohol abstinence and counseling) is recommended by 
both the American Association for the Study of Liver Diseases and the American College of 
Gastroenterology in published practice guidelines
(5, 16) [PMID 20034030, PMID 9820369]. 
3. Concise Summary of the Project: 
Our studies will test the hypothesis that the syndrome of acute alcoholic hepatitis (AAH) results from 
severe inflammation and dysregulated cytokines, providing the “second hit” that causes an acute 
deterioration. We further hypothesize that gut derived endotoxins and other bacterial products trigger 
inflammation and are a consequence of increased permeability with altered gut barrier function. 
We will utilize published models for predicting mortality in patients with AAH to stratify patients 
based on severity. Although previous studies of treatment for severe AAH utilized 30-day mortality 
as an endpoint, 6-month mortality is a more relevant outcome, in part because most transplantation 
programs require 6 months of abstinence before active listing. Furthermore, the number of deaths 
between 6 and12 months in abstinent patients is low compared to the number in the first 6 months. 
Patients will be stratified into those with Model of End-stage Liver Disease (MELD) score < 20 and 
MELD > 20. Those stratified into the severe group are described in a separate application. The 
primary difference between the Maddrey discriminant function (DF) and the MELD is that the latter 
includes creatinine. We propose to use the MELD score to stratify for severity. 
 

Page 3 of 16 
 
 
Specific Aim 1 = Randomized controlled trial for moderate alcoholic hepatitis: MELD < 20: 
Patients with moderate AAH will be randomized to receive either standard of care plus placebo or 
standard of care plus probiotic capsules in a 1:1 ratio. 
The primary outcome will be 30-day change in MELD score from baseline. Secondary 
outcomes will be change in MELD score from baseline at 90 and 180 days and changes from 
baseline in the gut mucosal integrity as assessed by the lactulose/mannitol test. Changes in serum 
endotoxin levels and cytokine profiles including TNFα will also be measured as secondary outcomes. 
We predict that probiotics will stabilize gut-barrier function, decrease endotoxemia, 
accelerate improvement in liver enzymes, and may slow or prevent progression of liver 
disease. 
Specific Aim 2 = Natural history of moderately severe acute alcoholic hepatitis: MELD < 20: 
Patients with moderately severe AAH/alcoholic liver disease who decline to be randomized but 
consent to prospective data collection and minimal risk non-invasive studies (blood drawing and 
urine collection) 
Specific Aim 3 = Subjects will be asked for a DNA blood draw during the first day of the study 
All human subjects will be patients with a clinical presentation consistent with acute alcoholic 
hepatitis (AAH). The trial is designed to test the hypothesis that AAH results from inflammation 
triggered by gut derived endotoxins and other bacterial products as a consequence of increased 
permeability of the gut mucosa. Patients with AAH will be stratified by disease severity as 
determined by the Model for End-Stage Liver Disease (MELD) score and enrolled in one of two 
randomized controlled trials. 
Subject population: The total subject population will be 260 patients with alcoholic hepatitis, 130 in 
each disease severity group (moderate disease is defined as MELD < 21 and severe disease as 
MELD 21 – 31 and MELD > 31). The age range will be 21 – 70 years old. The health status of the 
population will be that of a group with significant acute clinical presentation from alcoholic liver 

Page 4 of 16 
 
disease. 
Sampling plan: The sample size was calculated based on the analysis of patients with alcoholic 
liver disease in the (SRTR) database, accounting for drop-out, lost-to-follow-up and non-evaluable 
results and including a factor for possible non-representativeness of the original database. In 
addition, preliminary data for 114 patients meeting criteria were used in the calculations and 
stratification decisions. 
 
4. Criteria for Inclusion of Subjects: 
a) Ability to provide informed consent by subject or appropriate family member 
b) Age between 21-70 years 
c) Recent alcohol consumption > 50 g/d for > 6 months, continuing within two months before 
enrollment 
d) At least 2 of the following symptoms or signs of acute alcoholic hepatitis: Anorexia, nausea, 
RUQ pain, jaundice, leukocytosis, hepatomegaly AND 
e) Elevation of AST ≥ 50 U/L, but < 500 U/L; AST > ALT and ALT < 200 U/L; total bilirubin > 3 
mg/dL AND 
f) Liver biopsy showing alcoholic hepatitis (steatohepatitis) OR ultrasound of liver showing 
increased echogenicity OR CT scan showing decreased attenuation of liver compared to 
spleen OR MRI showing fatty liver (decreased signaling intensity on T1 weighted images):  
g) Model for End-Stage Liver Disease (MELD) <20 
 
5. Criteria for Exclusion of Subjects: 
a) Hypotension with BP < 80/50 after volume repletion 
b) Pregnancy; incarceration; inability to provide consent or lack of appropriate family member 
c) Signs of systemic infection: Fever > 38
o C and positive blood or ascites cultures on 
appropriate antibiotic therapy for > 3 days within 3 days of inclusion 
d) Acute gastrointestinal bleeding requiring > 2 units blood transfusion within the previous 4 
days 
e) Undue risk from immunosuppression: Positive HBsAg; a positive skin PPD skin test or 
history of treatment for tuberculosis; history of any malignancy including hepatocellular 
carcinoma; known HIV infection 
f) Previous treatment with corticosteroids or other immunosuppressive medications including 
specific anti-TNF therapy (not including pentoxifylline), calcineurin inhibitors within the 
previous 3 months 
g) Evidence of acute pancreatitis: CT evidence or amylase or lipase > 4 X ULN 
h) Serious cardiac, respiratory or neurologic disease or evidence of autoimmune hepatitis, 
primary biliary cirrhosis, primary sclerosing cholangitis, Wilson disease, hemochromatosis, 
secondary ion overload due to chronic hemolysis, alpha-1-antitrypsin deficiency 
6. Study Procedures: 
Aim 1 
Patients will be screened, stratified as moderate or severe acute alcoholic hepatitis and randomized 
to one of two arms for the clinical trial. Randomization will be in blocks of 6 using a sealed, opaque 
envelope. The study procedures are tabulated and divided into standard of care (“Standard”) and 
research-specific (“Research”) studies. Between days 2 and 7, between days 8 and 27, at 2 months, 
4 months and 5 months follow-up, clinically indicated standard studies will be obtained. Study 

Page 5 of 16 
 
procedures are described in the table. 
 
Study Procedures by Study Day: 
A summary of evaluations is located in the schedule of events table provided at the end of this 
section. The procedures and evaluations are outlined below. 
 
Screening: 
Complete screening for eligibility will occur once the informed consent has been obtained as 
described above. Patients will be evaluated on the basis of clinical and laboratory data during pre-
screening and stratified into moderate or severe alcoholic hepatitis. Patients will be evaluated for 
entry into the study according to the stated inclusion and exclusion criteria. Individuals who are 
identified during screening as not eligible for the study need not complete all screening procedures 
but will be provided the option to enroll in the natural history study. The reason for ineligible status 
will be documented on the Screen Failure Log. 
 
The following procedures will be obtained or performed to evaluate each patient’s general health 
and qualifications for participation in the study: 
 
Signed, written informed consent 
 
Demographic information including gender, date of birth, race and ethnicity. 
 
Medication history over the past 30 days, including prescription and non-prescription  over-
the-counter medications, herbal medications, vitamins and minerals. 
 
Alcohol usage in the past 60 days prior to assessment specifically and the pattern of  chronic 
usage. 
 
Review inclusion and exclusion criteria 
 
Collection of blood for hematology, coagulation, clinical chemistry to include amylase  and 
lipase, ammonia, and in female patients, a pregnancy test. 
 
Physical examination, including height, weight (body mass index will be calculated  based on 
these variables), and vital signs (systolic and diastolic blood pressure, pulse   rate, 
respiratory rate and body temperature) 
 
Ultrasound of the belly if no x-rays already obtained. This is standard of care in patients  
hospitalized with alcoholic hepatitis.   
 
Assessments at baseline and during study treatment:   
Study day 0 – baseline (within 24 hours of study enrollment) 
 
Complete collection of all baseline history. Review of alcohol use history using the  validated 
timeline 
followback 
method. 
Forms 
http://www.nova.edu/gsc/online_files.html 
 
(http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/InstrumentPDFs/13_TLFB.pdf) 
 
Complete collection of all indicated standard of care laboratory evaluations (chemistry,  
hematology, coagulation, urine, microbiology, viral, and TB testing). 
 
Ascites evaluation, if present. 
 
Collection of baseline research testing to include urine, blood, DNA and stool testing. 
 
Collect prior and concomitant medications. 
 
Clinical assessment to include vital signs and physical exam details. 
 
Nutritional assessment with a hand grip dynamometer  
 
Treatment day 1 – time zero (alternatively note this as treatment day one with no time and above as 
study day 1 baseline) 
 
Begin continuous AE review and reporting 
 
Begin once daily dosing of oral study medication or placebo preparation. 
 

Page 6 of 16 
 
Treatment day 2: 
 
Inpatient assessment to include: 
 
Review baseline history for changes. Review alcohol intake history. 
 
Collection of prior and concomitant medications 
 
Clinical assessment including vital signs and physical exam details 
 
Collection of blood for clinically indicated laboratory studies. 
 
Collection of research laboratory studies including urine and blood. 
 
Complete 24 hour urine collection. 
 
Continue once daily dosing of oral study medication or placebo preparation. 
 
Continuous AE review and reporting.  
 
Treatment days 3-6: 
 
If patient remains inpatient or has clinically indicated outpatient visit: 
 
Review baseline history for changes. Review alcohol intake history. 
 
Collection of prior and concomitant medications 
 
Clinical assessment including vital signs and physical exam details 
 
Collection of blood for clinically indicated laboratory studies. 
 
Continue once daily dosing of oral study medication or placebo preparation. 
 
Continuous AE review and reporting.  
 
Treatment day 7 ± 2 days: 
 
Inpatient assessment or required outpatient clinic visit to include: 
 
Review baseline history for changes. Review alcohol intake history. 
 
Collection of prior and concomitant medications 
 
Clinical assessment including vital signs and physical exam details 
 
Collection of blood for clinically indicated laboratory studies. 
 
Collection of research laboratory studies including urine and blood. 
 
Continue once daily dosing of oral study medication or placebo preparation. 
 
Continuous AE review and reporting.  
 
Treatment days 8-14: 
 
If patient remains inpatient or has clinically indicated outpatient visit: 
 
Review baseline history for changes. Review alcohol intake history. 
 
Collection of prior and concomitant medications 
 
Clinical assessment including vital signs and physical exam details 
 
Collection of blood for clinically indicated laboratory studies. 
 
Continue once daily dosing of oral study medication or placebo preparation. 
 
Continuous AE review and reporting.  
 
Treatment days 15-27: 
 
If patient remains inpatient or has a clinically indicated outpatient visit: 
 
Review baseline history for changes. Review alcohol intake history. 
 
Collection of prior and concomitant medications 
 
Clinical assessment including vital signs and physical exam details 
 
Collection of blood for clinically indicated laboratory studies. 
 
Continue once daily dosing of oral study medication or placebo preparation.  
 
Continuous AE review and reporting. 
Treatment day 28 ± 2 days: 
 
Inpatient assessment or required outpatient clinic visit to include: 
 
Review baseline history for changes. Review alcohol intake history. 
 
Collection of prior and concomitant medications 
 
Clinical assessment including vital signs and physical exam details 

Page 7 of 16 
 
 
Collection of blood for clinically indicated laboratory studies. 
 
Collection of research laboratory studies including urine and blood. 
 
Continue once daily dosing of oral study medication or placebo preparation. 
 
Continuous AE review and reporting.  
 
Treatment day 29 to 2 months: 
 
Continue once daily dosing of oral study drug or placebo preparation. 
 
Continuous AE review and reporting. 
 
If patient remains inpatient during this interval or completes clinically indicated outpatient visit 
during this time, the following data will be recorded: 
 
Review baseline history for changes. Review alcohol intake history. 
 
Collection of prior and concomitant medications 
 
Clinical assessment including vital signs and physical exam details 
 
Collection of blood for clinically indicated laboratory studies.  
 
Treatment 3 months ± 2 weeks: 
 
Inpatient assessment or required outpatient clinic visit (noted as 3 mos on schedule of 
events table) to include: 
 
Review baseline history for changes. Review alcohol intake history. 
 
Collection of prior and concomitant medications 
 
Clinical assessment including vital signs and physical exam details 
 
Collection of blood for clinically indicated laboratory studies. 
 
Collection of research laboratory studies including urine and blood. 
 
Continue once daily dosing of oral study drug or oral placebo preparation 
 
Collection of research laboratory studies including urine and serum 
 
Continuous AE review and reporting.  
 
Treatment 4, 5 months ± 2 weeks: 
 
Continue once daily dosing of oral study drug or oral placebo preparation 
 
Continuous AE review and reporting. 
 
If patient remains inpatient or completes clinically indicated outpatient visit during this time, 
the following data will be collected and recorded at the closest interval month: 
 
Review baseline history for changes. Review alcohol intake history. 
 
Collection of prior and concomitant medications 
 
Clinical assessment including vital signs and physical exam details 
 
Collection of blood for clinically indicated laboratory studies.  
 
Treatment 6 months ± 2 weeks: 
 
STOP all study and placebo medications. 
 
Complete abdominal ultrasound. 
 
Inpatient assessment or required outpatient clinic visit to include: 
 
 Review baseline history for changes. Review alcohol intake history. 
 
Collection of prior and concomitant medications 
 
Clinical assessment including vital signs and physical exam details 
 
Collection of blood for clinically indicated laboratory studies. 
 
Collection of research laboratory studies including urine, blood and stool. 
 
Continuous AE review and reporting. 
Follow up of early termination: 
A safety follow up visit will be performed approximately 30 days after discontinuation of study drug 
for all patients that discontinued without withdrawing informed consent. Evaluation will include: 
 
Collection of blood for standard of care labs to include chemistry, hematology and 
coagulation studies. 

Page 8 of 16 
 
 
Clinical assessment to include vital signs and physical exam details. 
 
Review baseline history for changes. Review alcohol intake history. 
 
Collection of concomitant medications. 
 
AE review and reporting. 
 
Review and recording of reason for early termination. 
 
 

Page 9 of 16 
 
Purpose 
Test 
Day 0  
Day  
2 – 6* 
Day 7 
Day  
8 – 27*  Day 28 
2  
mos *† 
3  
mos † 
4  
mos *† 
5  
mos *† 
6  
mos † 
Standard 
Clinical assessment  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Alcohol intake 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Liver 
panel 
(bilirubin, 
alkaline 
phosphatase, AST, ALT) and GGT 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Serum electrolytes, creatinine, BUN 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Serum albumin, total protein 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Prothrombin time, INR 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Complete blood count 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Haptoglobin 
x 
 
 
 
 
 
 
 
 
x 
 
Lipid panel 
x 
 
 
 
 
 
 
 
 
x 
 
Amylase, lipase 
x 
 
 
 
 
 
 
 
 
 
 
HIV 
x 
 
 
 
 
 
 
 
 
 
 
HAV Ab, HBsAg, HBcore Ab (total)  
x 
 
 
 
 
 
 
 
 
 
 
HCV Ab 
x 
 
 
 
 
 
 
 
 
 
 
PPD 
x 
 
 
 
 
 
 
 
 
 
 
Blood cultures x2 
x 
 
 
 
 
 
 
 
 
 
 
Urine culture & urinalysis 
x 
 
 
 
 
 
 
 
 
 
 
24 hour urine  
(Na, K, creatinine, protein) 
x 
 
 
 
 
 
 
 
 
 
 
Urine toxicology 
x 
 
 
 
 
 
 
 
 
 
 
Ascites for albumin, total protein, cell 
count and differential (if present) 
x 
 
 
 
 
 
 
 
 
 
 
Ascites culture 
x 
 
 
 
 
 
 
 
 
 
 
Stool studies (if diarrhea): C. difficile, 
culture 
x 
 
 
 
 
 
 
 
 
 
 
CXR 
x 
 
 
 
 
 
 
 
 
 
 
Complete abdominal ultrasound or 
cross-sectional radiology 
x 
 
 
 
 
 
 
 
 
x 
Research 
Gut permeability studies 
x ‡ 
 
 
 
x 
 
x 
 
 
x 
 
Serum zinc, urine zinc 
x 
 
 
 
x 
 
 
 
 
x 
 
Stool (DNA microbiome) 
x 
 
 
 
 
 
 
 
 
x 
 
Urine (KIM-1) 
x 
x day2 
x 
 
x 
 
x 
 
 
x 
 
Biomarkers = Cytokines 
x 
x day2 
x 
 
x 
 
x 
 
 
x 
 
DNA = Pharmacogenomics 
x 
 
 
 
 
 
 
 
 
 
 
Serum micro RNA 
x 
 
x 
 
x 
 
x 
 
 
X 
 
Monocyte prep (U Mass, U Louisville) 
x 
 
x 
 
 
 
 
 
 
X 
Blood 
Research total volume = 179 mL 
45 
  
30 
  
37 
  
30 
  
  
37 
 
SOC total volume = 208 mL 
82 
14 
14 
14 
14 
14 
14 
14 
14 
14 
 
Combined = 387 mL = 26 tbspns 
117 
14 
44 
14 
51 
14 
44 
14 
14 
51 
* clinically indicated, † ± 2 weeks, ‡ within first 28 days  

Page 10 of 16 
 
Sub-Study Procedures: 
1. Optional Natural History (minimal risk with urine and blood collection): All screened subjects 
meeting inclusion and exclusion criteria below or declining consent to randomization will be 
invited to join this study of the natural history of severe acute alcoholic hepatitis. The natural 
history of patients with severe alcoholic hepatitis is not well documented in the current era. 
Prospective collection of data in parallel with the randomized study subjects has great 
potential value. Every patient who agrees and give consent will be seen in follow-up as 
clinically indicated. At each visit that coincides with collection of samples for research, or as 
close to Baseline, Day 7, Day 28, Month 3 and 6, the subjects will be offered the opportunity 
to participate. Patients may also be asked to participate in the natural history study as a one-
time draw at the day of consent.  
4.a. Criteria for Inclusion of Subjects for Natural History Specimen Collection: 
a. Ability to provide informed consent by subject or appropriate family member  
b. Age between 21-70  
c. Recent alcohol consumption > 50 g/d for > 6 months, continuing within six months before 
enrollment  AND/OR 
d. Suspected or proven alcoholic liver disease 
 
5. a. Criteria for Exclusion of Subjects for Natural History Specimen Collection:  
a. Pregnancy; incarceration; inability to provide consent or lack of appropriate family member  
b. Signs of uncontrolled systemic infection: Fever > 38o C; positive blood or ascites cultures on 
appropriate antibiotic therapy for >3 days within 3 days of inclusion  
c. Evidence of acute pancreatitis: CT evidence or amylase or lipase > 5 X ULN  
d. Evidence of other liver diseases such as autoimmune hepatitis, primary biliary cirrhosis, 
primary sclerosing cholangitis, Wilson disease, biopsy proven hemochromatosis, alpha-1-
antitrypsin deficiency 
 
Over the entire 6 months study period 387 mL of blood will be drawn, comprising 208 mL for 
standard of care tests and 89 mL for research studies. 
Optional DNA Blood Sample Collection: A biorepository can serve as a national resource for 
all studies related to acute alcoholic hepatitis. A major goal of the U-01 consortium is to 
share clinical samples. Our research group will use the samples and share with others for 
future studies on biomarkers for AAH severity/outcome, cost analysis, rationales for new 
therapies, etc. Blood and tissue samples will be collected as indicated in the table. Samples 
for DNA preparation will be shipped to the Cleveland Clinic and specimens will be shipped to 
those translational sites that are studying biomarkers or pharmacogenomics (U Mass, U 
Louisville). Specimens will only be identified by the unique study number. De-identified data 
obtained from the various pharmacogenomics, miRNA and transcriptosome screens will be 
placed on the website of the U-01 consortium and be available to the U-01 investigators 
throughout the study. 
The amount of blood that would be collected is 8 mL (2 tbspns) and it will be stored at the 
Cleveland Clinic Foundation as part of the NIH Tissue and Biorepository for Alcoholic 
Hepatitis Studies. 
 

Page 11 of 16 
 
7. Sources of Research Material:  
Specimens: Blood, urine, stool 
Blood for research purposes will be collected at the same time as blood for clinical care. Urine 
specimens will be collected either with clinical care samples or at special research visits during 
follow-up after discharge. All samples will only be identified using a unique study number and 
processed as necessary for local storage or shipping to central testing sites. 
Stool samples will be collected by giving a collection kit to the subjects. 
A unique study number will be assigned to each subject. The unique study number will be assigned 
centrally at the time of randomization and used to code all samples. The study site will be identified 
by the first digit (1 – 4), the subject by the last 3 digits and the disease stratification by the total 
number of digits (4 for moderate alcoholic hepatitis). This procedure allows any site to exceed 100 
subjects enrolled in either study. 
 
Data: Any past medical history, family history, social history (including dietary and occupational 
history), medications and other ingested supplements potentially related to etiology or complications 
of liver disease and alcohol consumption not provided in the electronic medical records. 
 
Electronic medical record: Data pertaining to current hospitalization, past medical history, family 
history, social history (including dietary and occupational history), medications and other ingested 
supplements potentially related to etiology or complications of liver disease and alcohol 
consumption; physical examination. 
Standard of care laboratory investigations: Results of routine blood chemistry tests = blood 
electrolytes, renal and liver function tests, pancreas enzymes, lipid panel, urine and fluid chemistry; 
hematology = complete blood count, coagulation and hemolysis studies, fluid cell counts; infectious 
diseases = viral hepatitis serologies, tests for HIV and tuberculosis; blood, urine and fluid cultures; 
stool culture and toxins. Results of routine radiology = chest x-ray, complete abdominal ultrasound. 
Data from the results of research studies: gut permeability, blood and urine zinc, blood DNA 
(genomics) and stool DNA (microbiome), blood micro RNA, blood and urine inflammation 
biomarkers, blood mononuclear cells responses. A measure of nutritional status will be obtained via 
a hand grip measurement with the JAMAR dynamometer.   
A list of study patients will be maintained in the electronic medical record at each site and in no other 
place. The list will be assigned to one investigator at each site. Access to the list, within the 
electronic medical record, will be granted to the other investigators and research nurses at the study 
site. The security of the electronic medical record will provide full protection to any individually 
identifiable private information. 
8. Recruitment Methods and Consenting Process: 
Potential patients will be identified from daily results of routine chemistry tests (bilirubin > 3 mg/dL, 
AST > ALT and > 1.5x upper limit of normal but < 500 U/L) and screened for inclusion and exclusion 
criteria. The primary physicians will be approached for permission to meet the patient and will 
introduce the researchers. 
The potential subject will be introduced to the researcher(s) by provider(s) on the healthcare team 
responsible for the hospitalization (inpatients) or encounter (Emergency Department or outpatient). 
The study will be discussed in detail, with a translator as needed, and the consent form explained. 

Page 12 of 16 
 
Subjects will be given a copy of the consent form to keep, with a Spanish fully translated version as 
needed. When they have made a decision, the consent will be signed and witnessed if they are 
agreeable to participating. The time frame is 7 days from initial identification as eligible until study 
enrollment. 
Circumstances for consent: Subjects will be approached by one of the physician investigators, in a 
confidential environment with family members present if desired. The information provided will be all 
that data in the IRB-approved consent form, using interpretation service as needed via hospital 
language lines. The consent document, in English or Spanish, will be given to the subject as 
described above. After agreement to participate, the form will be signed and witnessed; a complete 
copy of the entire document will be provided to the subject in English or Spanish as required. 
If the subject’s condition is considered mentally unable to provide informed consent by the primary 
management team then a legal representative will have the option to sign the consent form until 
such time as the subject regains capacity. One of the complications of severe alcoholic hepatitis is 
hepatic encephalopathy. If this complication is diagnosed clinically, then the legal representative will 
be required to sign the consent form until the encephalopathy has resolved. It is much less likely to 
occur in moderate alcoholic hepatitis. 
 
 
9. Potential Risks: 
Physical risks: 
Probiotics are bacteria normally found in the gastrointestinal tract. They are deliberately cultured in 
yogurts and are a nutritional supplement. 
Side effects 
Frequent 
>20% of subjects 
Occasional 
2 - 20% of subjects 
Rare 
Less than 2% of subjects 
Serious 
 
 
Infection with probiotic bacteria 
(1 adult) 
Less Serious 
 
 
 
Minor 
 
Burping Hiccups 
 
 
10. Subject Safety and Data Monitoring: 
Data Safety Monitoring Board (DSMB): The DSMB will consist of three experienced clinicians to 
exercise oversight of the safety of trial participants. It will be chaired by Dr. Willis Maddrey 
(Professor of Internal Medicine, UT Southwestern Medical Center), review periodic safety reports 
prepared by the trial biostatistician (Dr. Bruce Barton), request additional data/information (if 
necessary), and advise the trial Executive Committee regarding continuation/discontinuation of the 
study. 
The External Medical Safety Monitor (EMSM, Dr. Maddrey) will closely monitor the incidence rates 
of all adverse events reported, whether serious or not, throughout the study, and will alert the DSMB 
if a trend is observed. A summary of all AEs and SAEs, a summary of all reports, and a coded list of 
all subjects who were terminated from the study due to study-related adverse events, will be 
included in reports submitted by the DMSB to the IRBs. An annual report will be submitted to the 
IRBs at all participating sites. 

Page 13 of 16 
 
Clinical performance sites will report all fatal events, unanticipated problems and other serious 
adverse events and suspected adverse reactions to the Data Safety Monitoring Board (DSMB) and 
IRB by secure email within 24 hours of first knowledge of the event. Additionally, all current 
study data for that particular subject will be entered to allow for timely review by the EMSM, Dr. 
Willis Maddrey. 
11. Procedures to Maintain Confidentiality: 
Any time information is collected; there is a potential risk for loss of confidentiality. Every effort will 
be made to keep information confidential; however, this cannot be guaranteed. 
Privacy of individuals: The privacy of individuals will be protected by using confidential surroundings 
for all communications, eliciting and honoring requests for the inclusion and exclusion of family 
members and partners and following the institutions’ codes for ethical and professional conduct of 
research and patient-centered care. 
Confidentiality of data: No personally identifiable information will be recorded outside the electronic 
medical record. Only those individuals with rights to access the patient’s electronic medical record 
will know the identity of the study subjects. While no efforts at security are completely free of risk, 
this approach is such that the risk of accidental exposure is negligible. 
 
12. Potential Benefits: 
The potential benefits to every subject participating in the clinical trial are related to receiving optimal 
patient-centered care for their condition. This includes ensuring the mobilization of available 
resources for rehabilitation programs and the education of all involved patients and their families on 
the possible consequences of alcohol consumption, particularly in high risk sub- populations. While 
ideally occurring in the care of all patients with alcoholic hepatitis, the study team will provide 
patients with the personal healthcare navigation assistance that is not available to every individual. 
There may be immediate additional benefits to those in the active study arms if the outcomes are 
favorable. If the outcomes are favorable, all patients with severe alcoholic hepatitis may benefit from 
extrapolation of the findings. If the outcomes are negative, other subjects will be protected from the 
risks of treatment that has no additional benefit to convey. 
There is a potential societal benefit in the general outcomes of the clinical trial with respect to 
alcohol consumption, alcoholism and alcoholic liver disease. In addition, the potential financial 
benefits of a successful program are substantial. 
13. Biostatistics: 
Sample size for study of patients with moderate acute alcoholic hepatitis 
To compare change from baseline in the two groups of moderate AAH patients, we find that a two-
sided twosample t-test of change in MELD score from baseline (mean=17.0) to 30 days with an 
overall sample size of 108 patients (54 in each treatment group) achieves 80% power with an alpha 
level of 0.05 to detect a difference in mean change of MELD score of 5.0 in the control group 
compared to a mean change of 8.0 in the intervention (probiotic) group with a common estimated 
group MELD score standard deviation of 5.559. 
Adjusting for a total of 20% withdrawal, lost to follow-up or non-evaluable, we have n* = 108/ (1- 

Page 14 of 16 
 
0.20) = 108/.80 = 136 patients total or 68 patients in each treatment group. We expect that, in a 
multivariate model, we will have the power to detect smaller treatment group differences due to the 
partition of the variance among the predictors. 
Statistical analysis plan: Our primary analysis of change in MELD score from baseline to 30 days 
will be an unadjusted comparison of change (Day 30 – Baseline) using a standard two- group t-test 
at a two-sided alpha level of 0.05 with appropriate adjustment for unequal variances. We will also 
conduct secondary analyses to further investigate factors that influence the change as well as adjust 
for any imbalances in patient characteristics and covariates between treatment groups. Our initial 
model will be an Analysis of Covariance (ANCOVA) model with change in MELD score as the 
outcome and with treatment group (0=control, 1=probiotic) and baseline MELD score as predictors. 
Additional models will include patient characteristics such as age, gender, time since diagnosis as 
well as other covariates such as ALT, AST, and other laboratory measures at baseline. Finally, as it 
is likely that MELD score can be calculated throughout the duration of the study, we will use mixed 
models to analyze the longitudinal MELD score data. Mixed (random effects) models are used to 
adjust for the inherent correlation among the laboratory (and, thus, MELD score) measures on the 
same patient. We will consider treatment as a fixed effect, but most other factors as random effects. 
The model will also include a time metric, so that, rather than the change from baseline, we can use 
the coefficients of the times as estimates of the change from baseline (time=0), adjusted for the 
other factors in the model. So, for example, if MELD score is calculated at Days 0, 7, 14, 21, and 30, 
the model might look like: MELDt = β0 + β1*tx + β2*gender + β3*age + β4*Day7 + β5*Day14 + 
β6*Day21 + β7*Day30 where MELDt = MELD score at time t (t=0,7,14,21,30), β0...β7 = regression 
coefficients, tx = treatment (0=control, 1=probiotic), gender = patient’s gender (0=female, 1=male), 
age=patient’s age at last birthday, Day7 = MELD score at Day 7 (0=No, 1=Yes), ..., Day30 = MELD 
score at Day 30 (0=No, 1=Yes). This implies that the baseline MELD score is represented by 
Day7=Day14=Day21=Day30=0. Interpreting this model, which makes maximum use of all available 
MELD scores, the coefficient β4 is the estimate of the change in MELD score from baseline to Day 7, 
β5 is the estimate of the change in MELD score from baseline to Day 14, etc. By combining all of the 
information into a single model, we can adjust the MELD score changes for other factors as well as 
test for a difference in the slopes of the changes between the two treatment groups. The model can, 
of course, be extended beyond 30 days if measures are available. The fit of the model will be 
assessed primarily through the likelihood ratio test of the fitted model to the intercept only model. All 
coefficients will be tested for significance at a critical level of p=0.05. 
Sample size for study of patients with severe acute alcoholic hepatitis 
Using the Lakatos approach
(17) to estimating the sample size for a log-rank test, we find that a two-
sided logrank test with an overall sample size of 130 patients (65 patients each of the control and 
treatment groups) achieves 80.0% power at a 0.05 significance level to detect a hazard ratio of 
0.4447 when the proportion surviving at 6 months in the control group is 0.64 and 0.82 in the 
treatment group. The total study duration is 2.5 years of which subject accrual (entry) occurs in the 
first 2 years. We assume that the accrual pattern is uniform throughout the accrual period and that 
the proportion drop-out in each group is 0.10 during the 6 months with no treatment cross-overs. As 
a sensitivity analysis of these estimates, we used the Lachin- Foulkes approach
(18), a slightly less 
flexible approach and, with the same assumptions as above, we estimate 53 patients in each group, 
reasonably close to the Lakatos estimates. Thus, to be conservative in our estimates, we will set our 
sample size as 130 patients total or 65 patients in each treatment group. PASS II (NCSS, Kaysville, 
Utah) was used for all sample size calculations
(19). 
Statistical analysis plan: Our primary analysis of this outcome will be the unadjusted log-rank test 
of the Kaplan-Meier survival estimates for the two treatment groups at a two-sided alpha level of 
0.05 with survival censored at 6 months. Secondary analysis will use a Cox proportional hazards 

Page 15 of 16 
 
regression model (with survival censored at 6 months) to adjust the treatment difference in survival 
for patient characteristics (e.g., age, gender, time since diagnosis) and other covariates (e.g., ALT, 
AST, other lab measures). Predictors will be added to the model using reference cell coding, as with 
the mixed models above. The Cox model generates estimates of the hazard ratio for each factor 
compared to the reference level; e.g., for male patients vs. female patients, assuming gender = 1 for 
male and 0 for females, a hazard ratio of 1.25 indicates that males have a 25% higher probability of 
death overall by 6 months compared to females. We can also add time-dependent covariates to the 
model, such as ALT levels at 2 and 4 months, to estimate their predictive value for mortality. To 
assess the fit of the model, we will use Nagelkerke’s R2 constructed from the ratio of the likelihoods 
for the fitted model to the intercept only model. As further secondary analysis, we can eliminate the 
survival censoring at 6 months and test the overall survival throughout the duration of follow-up. 
General analysis plan for experiments with fold change as the outcome: Initial analyses will be 
descriptive in nature, allowing for investigation of appropriate normalization approaches. Initial 
comparative analyses of fold-change between treatment groups (or between other groups of 
interest) will be through a standard two-group t-test at the p=0.05 level with appropriate adjustment 
for unequal variances. If the fold change data are longitudinal in nature, we will use mixed (random 
effects) models to estimate the change in fold-change over time. In these models, fold-change at 
each time point will be the outcome with treatment (or other group indicator) and time as predictors. 
Additional patient characteristics can be added to the model to create adjusted estimates of 
treatment (or other group) differences. Mixed models can adjust for the correlation due to measures 
within patients and due to repeated microarrays at each time point. 
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