From the Guidelines
Autoimmune hepatitis should be treated with prednisolone as initial therapy followed by the addition of azathioprine after two weeks as the first line treatment. This approach is based on the most recent and highest quality study available, which prioritizes morbidity, mortality, and quality of life as the outcome 1. The goal of treatment is to achieve complete biochemical remission, defined as normal ALT, AST, IgG levels, and resolution of symptoms.
Treatment Approach
The treatment typically involves immunosuppressive medications, starting with prednisone at 30-60mg daily, often combined with azathioprine at 50-150mg daily. The prednisone is gradually tapered to a maintenance dose of 5-10mg daily while continuing azathioprine. This combination therapy reduces side effects compared to prednisone alone 1.
Alternative Therapies
For patients who don't respond or can't tolerate standard therapy, alternatives include mycophenolate mofetil, cyclosporine, tacrolimus, or biologics like rituximab. Treatment is long-term, often lifelong, with regular liver function tests to monitor response.
Importance of Complete Biochemical Remission
Complete normalization of transaminases as well as normalisation of IgG levels should be the aim of treatment in patients with autoimmune hepatitis as persisting elevations of transaminases are predictive of a relapse after treatment withdrawal, activity on liver biopsy, progression to cirrhosis, and poor outcome 1.
Disease Progression and Complications
Without treatment, autoimmune hepatitis can progress to cirrhosis, liver failure, and increased risk of liver cancer. The disease results from a combination of genetic predisposition and environmental triggers causing T-cell mediated damage to hepatocytes, with characteristic features including elevated liver enzymes, high immunoglobulin G levels, and presence of autoantibodies like ANA and anti-smooth muscle antibodies.
Key points to consider in the management of autoimmune hepatitis include:
- Early diagnosis and treatment to prevent disease progression
- Use of immunosuppressive medications as first-line treatment
- Regular monitoring of liver function tests to adjust treatment as needed
- Consideration of alternative therapies for patients who don't respond or can't tolerate standard treatment.
From the Research
Treatment Strategies for Autoimmune Hepatitis
- The treatment of autoimmune hepatitis typically involves the use of immunosuppressive medications, such as prednisone and azathioprine, to reduce liver inflammation and prevent further damage 2.
- The combination of prednisone and azathioprine is often preferred due to its lower frequency of corticosteroid-related side effects 2.
- Treatment must be individualized for patients with mild-to-moderate disease, while those with severe inflammatory activity have absolute indications for therapy 2.
Efficacy of Different Treatment Regimens
- A study comparing the efficacy of different treatment regimens found that a combination of prednisone and azathioprine was more effective than prednisone alone or azathioprine introduced after 4 weeks of prednisone treatment 3.
- Another study found that mycophenolate mofetil (MMF) was a more efficient alternative to azathioprine, with lower non-response rates and higher complete biochemical response rates at 12 months and the end of follow-up 4.
- MMF was also found to be safer than azathioprine, with fewer serious complications and more frequent eligibility for stopping immunosuppression according to guidelines 4.
Alternative Treatment Options
- Alternative treatment options, such as cyclosporine, tacrolimus, and mycophenolate mofetil, have been shown to be effective in treating autoimmune hepatitis, particularly in patients who are intolerant to standard therapies 5, 6.
- Budesonide combined with azathioprine has also been found to be effective in normalizing liver parameters and reducing side effects compared to prednisone combined with azathioprine 6.
- Molecular interventions, such as monoclonal antibodies to CD3 and recombinant cytotoxic T lymphocyte antigen 4 fused with immunoglobulin, are also being studied as potential treatments for autoimmune hepatitis 6.