Does prednisone help medication-induced hepatitis?

From the Guidelines

Prednisone is not generally recommended for medication-induced hepatitis and may actually worsen the condition in most cases. The primary treatment for drug-induced liver injury is discontinuation of the offending medication. Prednisone, a corticosteroid, is only considered in specific circumstances such as autoimmune-like drug-induced hepatitis or cases with severe inflammatory features where other treatments have failed, as seen in the management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy 1.

When used, prednisone is typically started at a dose equivalent to 1-2 mg/kg methylprednisolone, as recommended for the management of immune-related adverse events 1. However, the use of corticosteroids in medication-induced hepatitis should be approached with caution, as they can themselves cause liver injury and may mask symptoms of worsening hepatic damage while potentially delaying recovery in many cases.

The best approach for medication-induced hepatitis includes:

• Stopping the causative drug
• Avoiding alcohol and other hepatotoxic substances
• Supportive care while the liver heals naturally Any consideration of prednisone therapy should be made by specialists familiar with drug-induced liver injury patterns and treatment protocols. The most recent and highest quality study on the management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy provides guidance on the use of steroids in this context 1.

In cases where prednisone is considered, it is essential to monitor liver function closely and taper the steroid dose carefully to minimize the risk of adverse effects. The decision to use prednisone should be based on a thorough evaluation of the patient's condition and the potential benefits and risks of treatment, as outlined in the guidelines for the management of autoimmune hepatitis 1.

It is also important to note that the use of prednisone in alcoholic liver disease is a separate consideration, and guidelines for this condition recommend a four-week course of prednisolone in patients with severe disease 1. However, this is a distinct clinical scenario from medication-induced hepatitis, and the use of prednisone in this context should be guided by the relevant clinical guidelines and expert opinion.

From the Research

Medication-Induced Hepatitis and Prednisone

• Prednisone is a corticosteroid that has been used to treat various forms of hepatitis, including autoimmune hepatitis and drug-induced liver injury (DILI) 2, 3, 4, 5, 6.
• In the context of medication-induced hepatitis, prednisone may be beneficial in certain cases, particularly those involving drug-induced autoimmune hepatitis (DI-AIH) 2, 6.
• The use of prednisone in DI-AIH has been associated with rapid and long-lasting effects, as well as a low risk of relapse after discontinuation of the medication 6.
• However, the efficacy of prednisone in other forms of DILI, such as moderate to severe DILI, is less clear, with some studies suggesting beneficial effects and others showing no improvement 6.

Treatment Strategies

• The treatment of medication-induced hepatitis with prednisone is often empirical and may be considered in patients who show no clinical improvement or have progressive liver injury despite cessation of the suspected drug 2.
• The combination of prednisone with other medications, such as azathioprine, may be used to treat autoimmune hepatitis and DI-AIH 3, 4, 5.
• The choice of treatment and the duration of therapy should be individualized based on the patient's symptoms, disease behavior, and response to treatment 3, 4.

Efficacy of Corticosteroids

• A systematic review of the role of corticosteroids in DILI found that the majority of studies analyzing the effects of corticosteroids in moderate to severe DILI demonstrated beneficial effects, although the observational design of these studies makes it difficult to draw conclusions on the efficacy of corticosteroids in DILI 6.
• The review also found that patients with DI-AIH had an excellent response to corticosteroids, while those with drug-induced fulminant acute liver failure did not show improved overall survival with steroid therapy 6.