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

Pharmacologic medical therapies for Autoimmune hepatitis include Prednisone alone and combination of Azathioprine and Prednisone

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 with Autoimmune Hepatitis:

Preferred regimen (1): Prednisone 60mg PO q24h for 7 days ( Preference:Cytopenia, Thiopurine methyltransferase deficiency, Pregnancy, Malignancy, Short-course (<6 months)
Preferred regimen (2): Prednisone 40mg PO q24h for next 7 days
Preferred regimen (3): Prednisone 30mg PO q24h for next 7 days
Preferred regimen (4): Prednisone 30mg PO q24h for next 7 days
Preferred regimen (5): Prednisone 20mg and below PO q24h for maintenance until endpoint
Alternative regimen: Combination Therapy which includes Prednisone and Azathioprine
Alternative regimen (1): Prednisone 30mg PO q24h for 7 days and Azathioprine 50mg q24h for 7 days
Alternative regimen (2): Prednisone 20mg PO q24h for 7 days and Azathioprine 50mg q24h for next 7 days

Alternative regimen (3): Prednisone 15mg PO q24h for 7 days and Azathioprine 50mg q24h for next 7 days
Alternative regimen (3): Prednisone 10mg PO q24h for 7 days and Azathioprine 50mg q24h for maintenance until endpoint

Immunosuppressive Treatment Regimens for Adults in Autoimmune Hepatitis
Monotherapy Prednisone only* (mg/day)		Combination Therapy
Weeks	Dosage	Prednisone	Azathioprine USA (mg/day) EU (mg/kg/day)
First	60	30	50	12
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 corticosteroids 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:

Pediatric

Preferred regimens:
- Initial regimen (1): Prednisone 1- 2 mg/kg (upto60mg/day) PO q24h for 14 days either alone or in combination with azathioprine, 1- 2 mg/kg q24h
- Maintenance regimen (2): Prednisone taper to 0.1 -0.2 mg/kg q24h or 5 mg q24h for 6 -8 weeks
  - if added initially, azathioprine at constant dose
  - Continue daily prednisone dose with or without azathioprine or switch to alternate day prednisone dose adjusted in response with or without azathioprine

Immunosuppressive Treatment Regimens for Children with 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

Frequency and Nature of Side Effects Associated with Treatment in Adults with Autoimmune Hepatitis
Prednisone-Related Side Effects		Azathioprine-Related Side Effects
Type	Frequency	Type	Frequency
Cosmetic (usually mild) Facial rounding Cytopenia Weight gain Dorsal hump striae Hirsutism Alopecia	80% (after 2 years)	Hematologic (mild) Cytopenia	46% (especially with cirrhosis)
Somatic (usually mild) Emotional instability Glucose intolerance Cataracts	13% (treatment ending)	Hematologic (severe) Leucopenia Thrombocytopenia	6% (treatment ending)
Somatic (severe) Osteopenia Vertebral compression Diabetes (brittle) Psychosis Hypertension (labile	13% (treatment ending)	Somatic (usually mild) Nausea Emesis Rash Fever Arthralgias	5%
Inflammatory/neoplastic Pancreatitis Opportunistic infection Malignancy	Rare	Neoplastic Nonhepatic cell types	3% (after 10 years)
		Hematologic/enteric Rare (treatment ending) Bone marrow failure Villous Atrophy Malabsorption Teratogenic during pregnancy	Rare

Contraindicated medications

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

Pegylated interferon alfa-2b

Sample

Immunosuppressive treatment with course of action in AIH

Drug treatment includes:
•Corticosteroids
•Azathioprine

Remission:
•Absence of symptoms
•Normal Serum Transaminase
•Normal bilirubin
•Normal gamma globulin level
•Normal histology or
inactive cirrhosis

Treatment failure:
•Worsening clinical
laboratory
and histological features
despite compliance
with therapy
Development of jaundice
,ascites or
hepatic encephalopathy

Incomplete response
Some or no improvement
in clinical,
laboratory,and histological
features despite
compliance with therapy
after 2-3 year

Drug toxicity
Development of intolerable
cosmetic changes,
symptomatic osteopenia,
emotional instability,
poorly controlled hypertension,
brittle diabetes
or progressive cytopenia

Gradual withdrawal
of prednisone over
6 week period
Serum AST or ALT
, total bilirubin,
and c globulin levels
determined 150 mg daily, for at least 1 monthDose reduction of
prednisone by 10mg
and azathioprine
by 50 mg for each
month of improvement
until standard
treatment doses
are achieved

Prednisone, 60 mg daily
, or prednisone,
30 mg daily,and azathioprine
, 150 mg daily, for
at least 1 month
Dose reduction of
prednisone by 10mg
and azathioprine by
50 mg for each month of improvement
until standard treatment doses
are achieved

Reduction in doses of prednisone
by 2.5 mg/month until
lowest level possible
(<10 mg daily) to prevent worsening
of serum AST or ALT abnormalities
Indefinite azathioprine therapy (2 mg/kg daily)
as an alternative treatment
if corticosteroid intolerance

Reduction in dose
or discontinuation of offending drug
Maintenance on tolerated
drug in adjusted dose

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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
1. Prednisone or prednisolone with azathioprine (adults)
2. Prednisone with azathioprine or 6-mercaptopurine (children)
3. 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}}

References

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