From the Guidelines
Treatment for autoimmune hepatitis should start with prednisone (30-60 mg daily) combined with azathioprine (50-150 mg daily) to reduce liver inflammation and prevent progression to cirrhosis, as this combination has been shown to improve survival, liver biochemical tests, and liver histology in patients with AIH 1. The standard initial therapy allows for lower steroid doses, reducing side effects, and treatment begins with a higher dose for induction, followed by a maintenance phase with gradual tapering of prednisone while continuing azathioprine. Some key points to consider in the treatment of autoimmune hepatitis include:
- The goal of treatment is to normalize liver enzymes, improve symptoms, and prevent disease progression by suppressing the abnormal immune response targeting the liver 1.
- Most patients require lifelong maintenance therapy, though some achieve complete remission.
- For those who don't respond to standard therapy, second-line options include mycophenolate mofetil, cyclosporine, tacrolimus, or rituximab.
- Regular monitoring of liver enzymes, complete blood counts, and drug levels is essential to assess treatment response and detect potential side effects.
- Patients should also receive appropriate vaccinations (particularly hepatitis A and B if not immune) and undergo screening for osteoporosis if on long-term steroids, as recommended by the British Society of Gastroenterology guidelines 1. The treatment regimen should be individualized, and patients who fail to achieve remission on standard therapy may require alternative treatments, such as higher doses of steroids or other immunosuppressive drugs. It is also important to note that patients with liver failure, bridging necrosis on biopsy, or jaundiced patients whose MELD score does not rapidly improve on treatment should be referred to a liver transplant center 1.
From the Research
Treatment Options for Autoimmune Hepatitis
- The primary goal of treatment is to achieve clinical and biochemical remission, which is associated with improved outcomes 2
- Induction treatment with corticosteroids and subsequent addition of steroid-sparing therapy with gradual tapering of corticosteroids remains the standard of care 2
- Alternative treatments to azathioprine include mycophenolate mofetil, tacrolimus, cyclosporine, sirolimus, or rituximab for those with intolerance or inadequate response to standard therapy 2
First-Line Treatment Options
- Mycophenolate mofetil (MMF) may be used as first-line treatment instead of azathioprine (AZA) in individuals with autoimmune hepatitis (AIH) 3
- MMF has been shown to have lower non-response rates and higher complete biochemical response rates compared to AZA 3
- Budesonide may be considered for induction in early disease and in those with mild fibrosis, but has not been approved for maintenance therapy 4
Salvage Therapies
- Cyclosporine and tacrolimus have been uniformly successful as salvage therapies for steroid-refractory autoimmune hepatitis 5
- Mycophenolate mofetil has been used as a salvage therapy with favorable outcomes, especially in patients with azathioprine intolerance 5
Future Therapeutic Options
- Biologics, including B-cell depleting agents, may be a promising step in expanding therapeutic options for autoimmune hepatitis 4
- Molecular interventions, such as monoclonal antibodies to CD3 and recombinant cytotoxic T lymphocyte antigen 4 fused with immunoglobulin, represent feasible molecular interventions for study in autoimmune hepatitis 5