Initial Medication Treatment for Autoimmune Hepatitis

Standard Induction Regimen

The European Association for the Study of Liver Diseases (EASL) recommends starting prednisone as initial therapy followed by addition of azathioprine after two weeks, particularly when bilirubin levels are below 6 mg/dL, in patients with moderate to severe disease 1
Combination therapy with prednisone (starting at 30 mg/day, tapering to 10 mg/day over 4 weeks) plus azathioprine (1-2 mg/kg/day) is superior to prednisone monotherapy because it produces significantly fewer corticosteroid-related side effects (10% versus 44%) while maintaining equivalent efficacy 4

Budesonide 9 mg/day plus azathioprine may be considered specifically in treatment-naive, non-cirrhotic patients with early-stage disease who are at high risk for steroid-specific side effects, such as psychosis, poorly controlled diabetes, or severe osteoporosis 1, 4

80-90% of patients achieve biochemical improvement with transaminases normalizing within 6 months in most responders 1, 4
Complete normalization of both transaminases AND IgG levels should be the goal, as persistent elevations predict relapse after treatment withdrawal, ongoing histological activity, progression to cirrhosis, and poor outcomes 1, 2

Continue treatment for at least 2 years and for at least 12 months after normalization of liver enzymes 2, 3

For confirmed non-responders, increase doses of prednisolone and azathioprine (up to azathioprine 2 mg/kg/day) 1, 2, 3

Patients with acute severe AIH require immediate treatment with high-dose intravenous corticosteroids (≥1 mg/kg) as early as possible 1

All patients must receive calcium and vitamin D supplementation from treatment initiation, DEXA scanning for bone mineral density monitoring at 1-2 year intervals, and vaccination against hepatitis A and B early in susceptible patients 2, 3

Relapse occurs in 50-90% of patients within 12 months of stopping treatment, and after relapse, long-term maintenance with azathioprine 2 mg/kg/day should be considered, with 87% of adult patients remaining in remission during median follow-up of 67 months 2, 3