Corticosteroid Therapy in Autoimmune Hepatitis

Indications and Treatment Regimens

The American Association for the Study of Liver Diseases recommends that corticosteroids, particularly prednisone or prednisolone, be initiated in all patients with active autoimmune hepatitis to prevent progression to cirrhosis and liver failure 1, 2
Treatment should be initiated in patients with serum aminotransferase levels >10-fold the upper limit of normal 3
Patients with serum aminotransferase levels >5-fold the upper limit of normal with serum γ-globulin levels at least twice the upper limit of normal should be treated 3
The European Association for the Study of the Liver recommends that patients with acute severe autoimmune hepatitis receive high-dose intravenous corticosteroids (≥1 mg/kg) as early as possible 4
The first-line regimen for adults is prednisone as initial therapy followed by addition of azathioprine after two weeks 4
The American College of Gastroenterology recommends that prednisone monotherapy be started with 60 mg/day, then tapered to 40 mg, 30 mg, and maintenance of 20 mg until endpoint 3, 5
Combination therapy with prednisone and azathioprine is associated with fewer corticosteroid-related side effects (10% vs. 44%) 3

High-dose intravenous corticosteroids (≥1 mg/kg) should be administered as early as possible in patients with acute severe autoimmune hepatitis 4, 1
If no improvement within 7 days, patients should be evaluated for liver transplantation 4, 1
Complete normalization of transaminases and IgG levels should be the aim of treatment 4
Serum aminotransferase levels should improve within 2 weeks of starting therapy 8
Biochemical remission achieved within 6 months is associated with lower frequency of progression to cirrhosis 8

80% of patients develop cosmetic changes (facial rounding, acne, dorsal hump, truncal obesity) after two years of corticosteroid therapy 3
Severe complications (osteoporosis, vertebral compression, diabetes, cataracts, hypertension, psychosis) typically develop after 18 months of therapy at prednisone doses >10 mg daily 3, 5
Patients on long-term corticosteroid treatment should be monitored for bone disease with baseline and annual bone mineral densitometry 5

The rapidity of response to treatment is the most important predictor of outcome 8
Elderly patients (≥60 years) respond more quickly to treatment than young adults 8
Non-response should prompt reconsideration of diagnosis and evaluation of treatment adherence 4
Advanced cirrhosis can impair conversion of prednisone to prednisolone, but this is usually not sufficient to alter treatment response 3