Autoimmune Hepatitis Treatment Guidelines

Introduction to Treatment

The American Association for the Study of Liver Diseases recommends prednisolone at 40 mg/day orally as the cornerstone first-line treatment for autoimmune hepatitis (AIH), achieving biochemical remission in 80% of patients within 6 months, and should be combined with azathioprine to minimize steroid-related side effects 1, 2

The European Association for the Study of the Liver suggests starting prednisolone immediately in patients meeting any of these criteria: serum aminotransferases >10-fold the upper limit of normal, serum aminotransferases >5-fold the upper limit of normal with serum γ-globulin levels at least twice the upper limit of normal, moderate to severe disease with symptoms, regardless of age, or any degree of cirrhosis with even mild histological activity 1, 3
The American Association for the Study of Liver Diseases recommends not treating asymptomatic older patients with mild AIH (Ishak necroinflammatory score <6) and no biochemical or histological evidence of active disease 1

The American College of Gastroenterology recommends a combination therapy of prednisolone 30 mg/day plus azathioprine 50 mg/day initially, then taper prednisolone to 10-20 mg/day maintenance, achieving 80% biochemical remission within 6 months and 75% histological remission after 18 months 1, 3
The European Association for the Study of the Liver suggests that this combination regime significantly reduces steroid-related side effects compared to monotherapy (10% vs 44%) 1, 3

The American Association for the Study of Liver Diseases recommends that serum aminotransferases should improve within 2 weeks of starting therapy, and the rapidity of response is the most important predictor of outcome 3
Complete biochemical remission requires both normal serum aminotransferases and normal IgG levels, and achieving remission within 6 months is associated with lower progression to cirrhosis 3, 4

The American College of Gastroenterology recommends increasing azathioprine to 2 mg/kg/day and gradually withdrawing prednisolone completely after achieving remission for at least one year on prednisolone plus azathioprine, maintaining remission in 83% of patients for a median of 67 months 5
The European Association for the Study of the Liver suggests retreating relapses identically to initial presentation, then maintaining on higher-dose azathioprine (2 mg/kg/day) long-term, particularly recommended for younger patients, LKM antibody-positive patients, and SLA-positive patients 5

The American Association for the Study of Liver Diseases recommends administering high-dose intravenous corticosteroids (≥1 mg/kg) as early as possible for acute severe AIH, and evaluating urgently for liver transplantation if no improvement within 7 days 3
The American College of Gastroenterology suggests not using budesonide in patients with established cirrhosis and portal hypertension, and continuing standard dosing in advanced cirrhosis despite potential impaired conversion of prednisone to prednisolone 4, 3

The European Association for the Study of the Liver recommends budesonide 9 mg/day plus azathioprine for treatment-naïve, non-cirrhotic patients, achieving faster normalization of transaminases with fewer side effects than prednisolone-based regimens, but notes that long-term histological remission data are lacking 1, 4