Autoimmune hepatitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Medical Therapy

Mainstay treatment of autoimmune hepatitis is pharmacotherapy. Corticosteroids alone or in combination with immunosuppressants are commonly used.

Acute Pharmacotherapies

Indications for Immunosuppressive Treatment
Absolute Indications	Relative Indications	None
Serum AST >10 fold upper limit of normal range(ULN)	Symptoms (fatigue, arthralgia, jaundice)	Asymptomatic with normal or near normal serum AST and gamma globulin levels
Serum AST >5 fold ULN	Serum AST and/or gamma globulin less than absolute criteria	Inactive cirrhosis or mild portal inflammation (portal hepatitis)
Gamma globulin level>2 fold ULN	Interface hepatitis	Severe cytopenia (white blood cell counts <2.5 x109/L or platelet counts <50 x 109/L)
Bridging necrosis or multiacinar necrosis on histological examination	Osteopenia, emotional instability, hypertension, diabetes, or cytopenia (white blood cell counts <2.5 x109/L or platelet counts <50 x109/L)
Incapacitating symptoms such as fatigue and arthralgia

Indications for Immunosuppressive Treatment

• Despite our clear understanding of the pathogenesis and pathophysiology of AH, approximately 80 % of patients will have a good initial response to corticosteroids, with a ten-year survival rate approaching 90%.
• The decision to treat patients with only mild disease is often based on symptoms.

• Asymptomatic patients with mild inflammation on Bx can be observed with careful monitoring of histology.

• The goal of therapy is generally normalization of both transaminases and histology, and in general, most patients who are going to respond do so by 6 months.
• Unfortunately, the results with alternate-day or pulsed steroid regimens have been disappointing and daily regimens are preferred.

• Azathioprine can be used as a steroid-sparing agent.
• Additionally, some authors recommend using lower prednisone doses with the goal of partial suppression of disease, as opposed to higher doses of steroids with the goal being remission.

• For the 10 – 20% of patients who develop progressive disease despite steroids and/or azathioprine, cyclosporine and tacrolimus have recently been shown to induce remission.
• There are no firm guidelines concerning the tapering or discontinuation of therapy.

Contraindicated medications

Autoimmune hepatitis is considered an absolute contraindication to the use of the following medications:

• Pegylated interferon alfa-2b

Recommendations for the Treatment of Autoimmune Hepatitis (DO NOT EDIT)

“

Immunosuppressive treatment based on serum aspartate aminotransferase (AST), serum alanine aminotransferase (ALT), serum gamma-globulin levels, and histological features Prednisone or prednisolone with azathioprine (adults) Prednisone with azathioprine or 6-mercaptopurine (children) Prednisone or prednisolone alone Monitoring for bone disease Adjunctive therapies for bone disease (weight bearing exercise program, vitamin D and calcium supplementation, bisphosphonates) Pretreatment vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) Management of treatment side effects and risks, including during pregnancy Alternative drug therapies for suboptimal response (cyclosporine, tacrolimus, or mycophenolate mofetil) Hepatic ultrasonography to detect hepatocellular carcinoma (HCC) Liver transplantation, management of recurrent disease after transplant with drug therapy and/or retransplantation in certain patients

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