Is prednisone (corticosteroid) effective for treating autoimmune hepatitis?

Prednisone Should Be Used for Autoimmune Hepatitis

Yes, prednisone is the cornerstone of treatment for autoimmune hepatitis and should be initiated immediately in all patients with active disease to prevent progression to cirrhosis and liver failure. 1, 2

Treatment Indications

Prednisone therapy is mandatory in the following situations:

• Serum aminotransferase levels >10-fold the upper limit of normal 1
• Serum aminotransferase levels >5-fold the upper limit of normal with serum γ-globulin levels at least twice the upper limit of normal 1
• Any patient with moderate-to-severe autoimmune hepatitis, which achieves biochemical remission in 80% of patients within 6 months 2

Preferred Treatment Regimens

The optimal approach is combination therapy with prednisone plus azathioprine, which reduces corticosteroid-related side effects from 44% to 10% compared to prednisone monotherapy. 1

Standard Dosing Algorithm:

For most patients:

• Start prednisone 30 mg/day + azathioprine 50 mg/day (US dosing) for week 1 2
• Taper prednisone gradually to maintenance doses over subsequent weeks 2

For patients with severe hyperbilirubinemia:

• Start prednisone first at 60 mg/day 1
• Add azathioprine after 2 weeks as a safer approach 2
• This prevents potential azathioprine hepatotoxicity in severely compromised livers 2

For prednisone monotherapy (when azathioprine contraindicated):

• Start 60 mg/day, then taper to 40 mg, 30 mg, and maintenance of 20 mg until endpoint 1

Acute Severe Autoimmune Hepatitis

This represents a medical emergency requiring immediate high-dose intravenous corticosteroids (≥1 mg/kg daily). 1, 2

Critical Management Algorithm:

1. Administer high-dose IV corticosteroids immediately (prednisone or prednisolone 0.5-1 mg/kg daily in adults, up to 2 mg/kg in children) 3
2. Monitor closely for 7 days 2
3. If no improvement within 7 days OR any clinical deterioration within 1-2 weeks, immediately evaluate for liver transplantation 3, 1, 2

Key distinction: Patients with acute severe AIH (without encephalopathy) should receive a treatment trial with corticosteroids, whereas patients with AIH and acute liver failure (with encephalopathy) should be evaluated directly for liver transplantation. 3

Critical Pitfall to Avoid:

Do not continue ineffective glucocorticoid therapy beyond 1-2 weeks in acute severe AIH. Failure to improve any laboratory test or evidence of clinical deterioration justifies immediate consideration of liver transplantation. 3 In patients with Model for End-Stage Liver Disease scores >40, glucocorticoid therapy has been associated with worse survival. 3

Monitoring Treatment Response

Serum aminotransferase levels should improve within 2 weeks of starting therapy—this is the most important predictor of outcome. 3, 1, 2

Response Timeline:

• Assess response at 4-8 weeks after treatment initiation 2
• Biochemical remission achieved within 6 months is associated with significantly lower frequency of progression to cirrhosis or need for liver transplantation 3, 1
• Complete normalization of BOTH serum aminotransferases AND IgG levels should be the treatment goal 1, 2

Treatment Duration:

• Continue treatment for at least 2 years and for at least 12 months after normalization of liver enzymes 2
• Sustained normal serum levels of AST, ALT, and IgG for at least 2 years are required before attempting treatment withdrawal 3

Management of Non-Response

For confirmed non-responders after 3 years, escalate to high-dose therapy: 2

• Prednisone 60 mg daily alone OR
• Prednisone 30 mg daily plus azathioprine 150 mg daily (or up to 2 mg/kg/day) for at least 1 month 2

For steroid-refractory cases, use alternative second-line agents including tacrolimus (superior to mycophenolate mofetil), cyclosporine, or mycophenolate mofetil. 2

Corticosteroid-Related Side Effects and Prevention

80% of patients develop cosmetic changes after 2 years of corticosteroid therapy, and severe complications typically develop after 18 months at prednisone doses >10 mg daily. 1

Mandatory Preventive Measures:

• All patients must receive calcium and vitamin D supplementation from treatment initiation 2
• Monitor bone mineral density with DEXA scanning at 1-2 year intervals 1, 2

Common Side Effects:

• Cosmetic changes (facial rounding, acne, dorsal hump, truncal obesity) 1
• Severe complications: osteoporosis, vertebral compression, diabetes, cataracts, hypertension, psychosis 1

Alternative for Select Patients

Budesonide 9 mg/day plus azathioprine may be used in treatment-naive, non-cirrhotic patients with early-stage disease who face high risk of steroid side effects. 2 However, budesonide should NOT be used in patients with cirrhosis or acute severe AIH. 2

Long-Term Management

Relapse occurs in 50-90% of patients within 12 months of stopping treatment. 2 Consider long-term maintenance with azathioprine 2 mg/kg/day, which maintains remission in 83-87% of adult patients. 2