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

According to American Association for the Study of Liver Diseases indications for immunosuppressive treatment:

Indications for Immunosuppressive Treatment
Absolute Indications	Relative Indications	None
Serum AST >10 fold upper limit of normal range(ULN)	Symptoms like 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)	complete deficiency of TPMT activity precludes treatment with azathioprine
Incapacitating symptoms such as fatigue and arthralgia		Vertebral compression, psychosis, brittle diabetes, uncontrolled hypertension, known intolerances to prednisone or azathioprine

According to American Association for the Study of Liver Diseases, Immunosuppressive Treatment Regimens for Adults in Autoimmune Hepatitis:

Immunosuppressive Treatment Regimens for Adults in Autoimmune Hepatitis
Monotherapy Prednisone only* (mg/day)		Combination Therapy
Weeks	Dosage	Prednisone* (mg/day)	Azathioprine
First	60	30	USA (mg/day)	EU (mg/kg/day)
Second	40	20	50	12
Third	30	15	50	12
Fourth	30	15	50	12
Maintenance until endpoint	20 and below	10	50	12
Reasons for Preference	Cytopenia, Thiopurine methyltransferase deficiency, Pregnancy, Malignancy, Short-course (<6 months)		Postmenopausal state, Brittle diabetes, Obesity, Acne, Emotional lability, Hypertension

Adjunctive therapies:

• Adjunctive therapy is based on medication and complication occurs due to medication

• The regular weight-bearing exercise program, vitamin D, calcium supplementation and bisphosphonates should be taken by patient who is taking corticosteriod for long term
• Vaccination against hepatitis B virus (HBV) and hepatitis A virus (HAV) should be done as early as possible even before immunosuppression

According to American Association for the Study of Liver Diseases, Immunosuppressive Treatment Regimens for Children in Autoimmune Hepatitis:

Immunosuppressive Treatment Regimens for Children in Autoimmune Hepatitis
Initial Regimen	Maintenance Regimen	Endpoint
Prednisone, 1 2 mg/kg daily (up to 60 mg/day), for two weeks either alone or in combination with azathioprine, 1 2 mg/kg daily	Prednisone taper over 6 8 weeks to 0.1 0.2 mg/kg daily or 5 mg daily Azathioprine at constant dose if added initially Continue daily prednisone dose with or without azathioprine or switch to alternate day prednisone dose adjusted to response with or without azathioprine	Normal liver tests for 1 2 years during treatment No flare during entire interval Liver biopsy examination discloses no inflammation

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)

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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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