From the Guidelines
The treatment for autoimmune hepatitis typically involves immunosuppressive medications to reduce liver inflammation, with the standard initial therapy consisting of prednisone (starting at 30-60 mg daily) alone or in combination with azathioprine (50-150 mg daily), as recommended by the American Association for the Study of Liver Diseases (AASLD) in their 2019 practice guidance and guidelines 1.
Key Components of Treatment
- The combination of prednisone and azathioprine allows for lower steroid doses, reducing side effects while maintaining efficacy.
- Treatment usually begins with higher doses that are gradually tapered over several weeks as liver enzymes normalize.
- Most patients require long-term maintenance therapy, often for years or lifelong.
Second-Line Options
- For those who don't respond to standard therapy, second-line options include mycophenolate mofetil, cyclosporine, tacrolimus, or biologics like rituximab.
Monitoring and Lifestyle Modifications
- Regular monitoring of liver function tests is essential to assess treatment response.
- Patients should also be monitored for medication side effects, including bone density testing for those on long-term steroids.
- Lifestyle modifications including avoiding alcohol, maintaining a healthy weight, and getting vaccinated against hepatitis A and B are also important components of management.
Treatment Goals
- Treatment aims to suppress inflammation, prevent progression to cirrhosis, and induce remission, which occurs in about 80% of patients with proper therapy, as supported by evidence from the EASL clinical practice guidelines 1 and other studies 1.
From the Research
Treatment Overview
- The primary treatment for autoimmune hepatitis is corticosteroid therapy, which induces clinical, laboratory, and histological improvements in 80% of patients 2.
- The combination of prednisone and azathioprine is the preferred treatment regimen, as it increases the 20-year life expectancy to 80% and prevents or reduces hepatic fibrosis in 79% of patients 2.
Treatment Regimens
- Prednisone alone or 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 due to its lower frequency of corticosteroid-related side effects 3.
- Mycophenolate mofetil is a second-line immunosuppressive agent that has shown promise in treating autoimmune hepatitis, particularly in patients who are intolerant of or refractory to conventional regimens 4, 5, 6.
Salvage Therapies
- Salvage therapies for individuals intolerant of or refractory to conventional regimens include high-dose corticosteroids, with or without high-dose azathioprine, 6-mercaptopurine, mycophenolate mofetil, tacrolimus, or ciclosporin 2.
- 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 2.
Treatment Outcomes
- Relapse after drug withdrawal occurs in 50-79% of patients, and it should be treated with long-term azathioprine (2 mg/kg daily) 2.
- Autoimmune hepatitis recurs after transplantation in at least 17% of patients, and it typically improves after adjustments in the immunosuppressive regimen 2.
- Approximately one of two patients with autoimmune hepatitis that fail standard treatment benefit from long-term maintenance with mycophenolate mofetil, especially those with previous intolerance to thiopurines 6.