What is the treatment for autoimmune hepatitis (AIH)?

From the Guidelines

The treatment for autoimmune hepatitis (AIH) is immunosuppressive therapy, specifically prednisone or prednisolone, either alone or in combination with azathioprine.

Treatment Regimens

• The standard of care (SOC) immunosuppressive therapy for AIH, as endorsed by international guidelines, is steroid therapy to induce biochemical remission, defined as normalization of both serum aminotransferase and immunoglobulin G (IgG) levels 1.
• The aim of treatment is to obtain complete remission of the disease and to prevent further progression of liver disease, which requires mostly permanent maintenance therapy or induction of a sustained remission following treatment withdrawal 1.
• Prednisone or prednisolone with or without azathioprine can induce biochemical improvement in as many as 90% of patients within 12 months, reduce hepatic fibrosis, and result in remission off therapy in 19%-40% of patients 1.

First-Line Treatment

• The first-line treatment of AIH is predniso(lo)ne as initial therapy followed by the addition of azathioprine after two weeks 1.
• Glucocorticoid and azathioprine therapy are recommended as first-line management for AIH, with the goal of achieving complete biochemical remission 1.

Special Considerations

• The benefits of immunosuppressive treatment in asymptomatic older patients with mild necroinflammatory activity on liver biopsy are not well established, and treatment-related side effects should be counterbalanced to the risk of sub-clinical disease progression 1.
• Patients with AIH and moderate or severe inflammation, symptoms, or established cirrhosis on liver biopsy should be offered immunosuppressive treatment due to the clear survival benefits in these patients 1.

From the Research

Treatment Overview

The treatment for autoimmune hepatitis (AIH) is primarily based on immunosuppression, with the goal of achieving clinical and biochemical remission 2, 3, 4.

First-Line Treatment

• The standard therapy for AIH typically involves the use of corticosteroids and azathioprine 2, 3, 5.
• This treatment approach has been shown to be effective in inducing remission in the majority of patients 3.

Second-Line Treatment

• For patients who are non-responders or intolerant to standard therapy, alternative immunosuppressive drugs may be considered 2, 5, 4.
• These alternatives may include mycophenolate mofetil, tacrolimus, cyclosporine, sirolimus, or rituximab 4.
• Budesonide may also be considered as an alternative in non-cirrhotic AIH patients to minimize unwanted steroid effects 5.

Treatment Outcomes

• Achieving clinical and biochemical remission is associated with significantly improved outcomes 4.
• Treatment withdrawal is achievable in less than 20% of patients after 2 years of sustained remission 4.
• Liver transplantation should be considered in those with progressive liver disease or complications such as hepatocellular carcinoma 5, 4.

Challenges in Treatment

• The treatment of AIH can be complex, with challenges including the avoidance of immunosuppressant side effects, non-responders to standard induction therapy, and adherence to therapy 5.
• Recurrent AIH after liver transplantation is also a concern, requiring lifelong vigilance and therapeutic attention 5.