Management of Autoimmune Hepatitis
The standard first-line treatment for autoimmune hepatitis is prednisolone (0.5-1 mg/kg/day) alone or in combination with azathioprine (1-2 mg/kg/day), which can induce biochemical remission in up to 90% of patients within 12 months. 1
First-Line Treatment Approach
Initial Therapy
- Corticosteroids: Prednisolone 30-60 mg/day initially (0.5-1 mg/kg/day)
- Combination therapy: Add azathioprine starting at 50 mg/day, increasing to maintenance dose of 1-2 mg/kg/day 1
Recommended Tapering Schedule (for a 60 kg patient)
| Week | Prednisolone (mg/day) | Azathioprine (mg/day) |
|---|---|---|
| 1 | 60 | - |
| 2 | 50 | - |
| 3 | 40 | 50 |
| 4 | 30 | 50 |
| 5 | 25 | 100 |
| 6 | 20 | 100 |
| 7-8 | 15 | 100 |
| 9-10 | 12.5 | 100 |
| >10 | 10 | 100 |
Monitoring Response
- Monitor serum AST/ALT and IgG levels at 3-6 month intervals 1
- Complete biochemical response: Normalization of both serum transaminases and IgG below the upper limit of normal within 6 months 1
- Weekly liver tests and blood counts for the first 4 weeks, then monthly once stable 1
Management of Treatment Failures
For Azathioprine Intolerance
- Mycophenolate mofetil: Most effective for azathioprine intolerance (58% response rate) 2
- Initial dose: 1 g daily, increasing to maintenance of 1.5-2 g daily
- Note: Category D in pregnancy; contraindicated in women planning pregnancy
For Refractory Disease
Calcineurin inhibitors:
Other second-line options for refractory cases:
Special Considerations
Pregnancy
- Pregnant patients are at risk for postpartum exacerbation
- Resume standard therapy 2 weeks prior to anticipated delivery
- Attempt to discontinue azathioprine during pregnancy if possible (FDA pregnancy category D) 1
Preventive Care
- All patients on steroids should receive calcium (1,000-1,200 mg daily) and vitamin D (400-800 IU daily) supplementation 1
- Consider vaccination against hepatitis A and B for susceptible patients 1
Liver Transplantation
- Consider referral for transplantation in patients with:
- Decompensation at presentation
- Severe disease with no or slow response to treatment
- Fulminant hepatic failure
- High MELD or Child-Pugh scores 1
Side Effects Management
- Up to 25% of patients may develop side effects requiring withdrawal in about 10% of cases 1
- Monitor for increased risk of infections, especially in non-responders to steroid therapy 1
- Early reactions to azathioprine (arthralgias, fever, skin rash, pancreatitis) may occur within days or weeks 1
This management approach aims to achieve complete biochemical remission, which is associated with significantly improved outcomes in terms of mortality, morbidity, and quality of life. Only about 20% of patients can successfully withdraw from treatment after 2 years of sustained remission 4.