From the Guidelines
Autoimmune hepatitis treatment should typically involve prednisolone plus azathioprine as initial therapy, with the goal of achieving complete biochemical remission. This approach is supported by the most recent and highest quality study, which recommends prednisolone and azathioprine as the first-line treatment for autoimmune hepatitis 1. The initial dose of prednisolone is typically 30 mg/day, reducing to 10 mg/day over 4 weeks, and azathioprine is started at 1 mg/kg/day 1.
Key Considerations
- The treatment aim is to achieve complete biochemical remission, defined as normalization of both serum aminotransferase and immunoglobulin G (IgG) levels, to reduce mortality and prevent disease progression 1.
- Regular monitoring of liver function tests is essential to assess treatment response and adjust medication dosages.
- Patients should be aware of potential side effects, including weight gain, mood changes, and increased infection risk with prednisone, and bone marrow suppression with azathioprine.
- Alternative medications, such as mycophenolate mofetil, cyclosporine, or tacrolimus, may be considered for patients who cannot tolerate or respond to standard therapy.
Treatment Duration and Monitoring
- Treatment is typically long-term, often lasting years or even lifelong, with the goal of maintaining complete biochemical remission.
- Liver biopsy to confirm histological remission is of value in planning further management 1.
- Patients should receive calcium and vitamin D supplementation, and bone DEXA scanning should be performed at 1-2 yearly intervals while on steroids to prevent osteopenia and osteoporosis 1.
From the Research
Treatment Options for Autoimmune Hepatitis
- The standard treatment for autoimmune hepatitis (AIH) includes corticosteroids alone or in combination with azathioprine 2, 3, 4.
- Alternative treatments, such as mycophenolate mofetil (MMF), cyclosporine, and tacrolimus, may be considered for patients who do not respond to standard therapy or experience side effects 5, 2, 6, 4.
- Budesonide may be considered for induction in early disease and in those with mild fibrosis, but has not been approved for maintenance therapy 6, 4.
Second-Line Therapies
- MMF may be used as a second-line maintenance agent, but results from a randomized trial are awaited 4.
- Tacrolimus may be an equally effective second-line option, particularly in non-responders, but data remain limited 6, 4.
- Cyclosporine has been uniformly successful as a salvage therapy for steroid-refractory AIH 6.
Future Therapeutic Options
- Biologics, including B-cell depleting agents, may be a promising step in expanding the scope of therapeutic options for AIH 4.
- Recent insights in understanding the pathogenesis of AIH could serve as a basis for future therapies, including the elucidation of different immunoregulatory pathways and the potential role of the intestinal microbiome 4.