From the Guidelines
The initial treatment for a patient with elevated smooth muscle antibodies (SMA) suggestive of autoimmune hepatitis is prednisolone as initial therapy followed by the addition of azathioprine after two weeks, as recommended by the EASL clinical practice guidelines (1). This approach is based on the principle of using steroid-based immunosuppressive treatment to improve serum transaminases to levels within the normal range.
- The goal of treatment is to achieve complete normalization of transaminases and IgG levels, as persisting elevations are predictive of relapse, activity on liver biopsy, progression to cirrhosis, and poor outcome (1).
- Regular monitoring of liver enzymes, bilirubin, and complete blood counts is essential during treatment to assess response and detect potential medication toxicity.
- The use of azathioprine as a steroid-sparing agent helps maintain remission while minimizing steroid-related side effects.
- It is worth noting that while other guidelines and studies provide additional information on the management of autoimmune hepatitis (1, 1), the most recent and highest quality study recommends the use of prednisolone and azathioprine as the first line treatment (1).
From the Research
Initial Treatment for Elevated Smooth Muscle Antibodies
The initial treatment for a patient with elevated smooth muscle antibodies (SMA) suggestive of autoimmune hepatitis (AIH) typically involves immunosuppressive therapy.
- Corticosteroids and azathioprine are commonly recommended as first-line treatments for AIH 2, 3.
- Mycophenolate mofetil (MMF) may be considered as an alternative first-line treatment option, particularly for patients who are intolerant to azathioprine or have an incomplete response to it 4.
- The goal of treatment is to achieve complete biochemical response, which is essential for long-term overall survival 2.
Treatment Response and Outcome
Studies have shown that MMF can be an effective alternative to azathioprine, with lower non-response rates and higher complete biochemical response rates at 12 months and the end of follow-up 4.
- Patients with elevated SMA and raised alanine aminotransferase (ALT) levels are at higher risk of developing AIH and should be referred to secondary care for investigation 5.
- Life-long maintenance treatment may be required for the majority of patients with AIH, as cessation of immunosuppressive agents can lead to relapse of the disease 2, 3.
Diagnosis and Clinical Manifestations
AIH is characterized by elevated aminotransferases, presence of anti-nuclear antibody or anti-smooth muscle antibody, elevated immunoglobulin G (IgG), and interface lympho-plasmacytic hepatitis 2, 3.