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
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) |
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| Weeks | Dosage | ||
| First | 60 | ||
| Second | 40 | ||
| Third | 30 | ||
| Fourth | 30 | ||
| Maintenance until endpoint | 20 and below | ||
- 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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