Drug therapy

All patients with autoimmune hepatitis should be managed by a liver specialist.

Autoimmune hepatitis is treated with immunosuppressive therapy, which should be individualised according to the patient response and tolerance of treatment. The goal of treatment is to normalise alanine aminotransferase (ALT) and immunoglobulin G (IgG) concentrations, which are a surrogate for histologic remission of active autoimmune hepatitis.

Prednisolone is used for initial treatment of autoimmune hepatitis; a typical regimen for adults is:

A prednisolone dose at the lower end of the range is used in patients with milder disease, older age, increased risk of adverse effects or lower weight. A dose at the upper end of the range may induce remission more rapidly.

Azathioprine is usually added to prednisolone as a steroid-sparing drug, for maintenance therapy of autoimmune hepatitis. It may be started after 2 weeks of prednisolone therapy, or when the bilirubin concentration has dropped to less than 100 micromol/L. A typical starting regimen for adults is:

A starting dose of azathioprine at the lower end of the range is used in older patients and those with low thiopurine methyltransferase (TPMT) concentrations (see monitoring azathioprine therapy below). Patients with autoimmune hepatitis often respond to lower doses of azathioprine compared with the doses required for other autoimmune diseases. In patients who do not tolerate azathioprine, switching to mycophenolate or mercaptopurine may be appropriate.

For information on antimicrobial prophylaxis in patients receiving immunosuppressive therapy, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection.

Most patients with autoimmune hepatitis need lifelong low-dose immunosuppressant therapy because the relapse rate is high (50 to 90%) if treatment is stopped. A liver biopsy may be considered to exclude ongoing disease activity histologically, particularly if treatment is ever stopped.