From the Guidelines
The first-line treatment for autoimmune hepatitis (AIH) should be prednisolone as initial therapy followed by the addition of azathioprine after two weeks, as this approach has been shown to effectively improve serum transaminases and reduce the risk of relapse, liver damage, and poor outcomes. This treatment strategy is based on the most recent and highest quality evidence available, including the 2015 EASL clinical practice guidelines 1 and the 2020 American Association for the Study of Liver Diseases (AASLD) practice guidance and guidelines 1.
Key Considerations
- The goal of treatment in AIH is to achieve complete normalization of transaminases and IgG levels, as persisting elevations are predictive of relapse, liver damage, and poor outcomes 1.
- The combination of prednisone and azathioprine allows for lower steroid doses, reducing side effects and improving patient outcomes.
- Regular monitoring of liver function tests is essential to assess treatment response and adjust therapy as needed.
- Patients should also receive appropriate vaccinations and undergo screening for bone density loss if on long-term steroids.
Treatment Approach
- Induction therapy with prednisone (starting at 40-60 mg daily) alone or combined with azathioprine (50-150 mg daily) should be followed by a maintenance phase with gradual tapering of prednisone while continuing azathioprine.
- Most patients require lifelong maintenance therapy, though some may achieve complete remission.
- Alternative medications, such as mycophenolate mofetil, cyclosporine, or tacrolimus, may be considered for patients who do not respond to standard therapy.
Disease Management
- Autoimmune hepatitis is a chronic inflammatory liver disease that results from a complex interaction between genetic predisposition and environmental triggers, causing T-cell mediated damage to hepatocytes.
- Without treatment, AIH can progress to cirrhosis, liver failure, and potentially require liver transplantation.
- Early diagnosis and treatment are critical to improving patient outcomes and reducing the risk of long-term complications.
From the Research
Definition and Treatment of Autoimmune Hepatitis
- Autoimmune hepatitis is a chronic syndrome characterized by autoimmunologic features, including the presence of circulating autoantibodies and high serum globulin concentrations 2.
- The American Association for the Study of Liver Diseases (AASLD) recommends initial treatment or induction therapy for autoimmune hepatitis to involve a glucocorticoid alone or a combination of a glucocorticoid and an immunosuppressant 2.
Treatment Regimens and Efficacy
- A study comparing the efficacy of different treatment regimens found that better efficacy was achieved in the induction phase using a combination of Prednisone and Azathioprine from the beginning of the treatment course 2.
- Another study found that Prednisone alone or a lower dose in combination with azathioprine is effective in improving symptoms, resolving laboratory and histologic features, and prolonging survival in patients with autoimmune hepatitis 3.
- The combination regimen of prednisone and azathioprine is preferred because of its lower frequency of corticosteroid-related side effects 3, 4.
Medication and Treatment Duration
- Medication should be continued at fixed daily maintenance levels until a remission, treatment failure, drug intolerance, or incomplete response has been established 3.
- Treatment must be individualized in patients with mild-to-moderate disease, and histologic examination before drug withdrawal ensures remission when symptoms and laboratory tests are normal or near normal 3.
- The duration of therapy is finite, and the medication should be discontinued after resolution of all manifestations of inflammatory activity, including the histological changes 5.
Relapse and Salvage Therapies
- Relapse after drug withdrawal occurs in 50-79% of patients, and it should be treated with long-term azathioprine (2 mg/kg daily) 5.
- Salvage therapies for individuals intolerant of or refractory to the conventional regimens include high-dose corticosteroids, with or without high-dose azathioprine, 6-mercaptopurine, mycophenolate mofetil, tacrolimus or ciclosporin 5, 4.
- Liver transplantation should be considered in patients with hepatic failure unresponsive to corticosteroid treatment, decompensated cirrhosis with a Model for End-Stage Liver Disease score of at least 15 points, or hepatocellular carcinoma that meets transplantation criteria 5, 4.