Autoimmune hepatitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
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) |
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| Incapacitating symptoms such as fatigue
and arthralgia |
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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:
Recommendations for the Treatment of Autoimmune Hepatitis (DO NOT EDIT)
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