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Autoimmune hepatitis: Treatment

Author
Michael A Heneghan, MD, MMedSc, FRCPI
Section Editors
Sanjiv Chopra, MD, MACP
Elizabeth B Rand, MD
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF

INTRODUCTION

Autoimmune hepatitis is a chronic hepatitis characterized by immunologic and autoimmune features, generally including the presence of circulating autoantibodies and a high serum gamma globulin concentration [1].

Type 1, or classic autoimmune hepatitis, is characterized by circulating antinuclear antibodies and/or anti-smooth muscle antibodies. It is the predominant form of autoimmune hepatitis seen in adults and adolescents (table 1) [2]. Type 2 autoimmune hepatitis is defined by the presence of antibodies to liver/kidney microsomes (ALKM-1) and/or to a liver cytosol antigen (ALC-1). It is typically diagnosed in infants, girls, and young women. (See "Autoimmune hepatitis: Disease classification", section on 'Classification' and "Autoimmune hepatitis: Clinical manifestations and diagnosis".)

This topic will review the treatment of autoimmune hepatitis. The pathogenesis, clinical manifestations, and diagnosis of autoimmune hepatitis, as well as the treatment of variants of autoimmune hepatitis, are discussed separately. (See "Autoimmune hepatitis: Pathogenesis" and "Autoimmune hepatitis: Clinical manifestations and diagnosis" and "Autoimmune hepatitis: Associated extrahepatic disorders" and "Autoimmune hepatitis: Serologic markers" and "Autoimmune hepatitis: Disease classification" and "Autoimmune hepatitis variants: Definitions and treatment".)

The discussion that follows represents our approach to the treatment of autoimmune hepatitis. Treatment recommendations have also been outlined in 2010 guidelines from the American Association for the Study of Liver Diseases [3] and in 2011 guidelines from the British Society of Gastroenterology [4]. Our approach and the approaches in the two guidelines are similar, but they do vary in some areas such as what level of aminotransferase elevation is required to initiate treatment and the specific approaches to treatment (eg, whether to initiate treatment with a glucocorticoid alone or in combination with azathioprine and when to recommend maintenance therapy).

REFERRAL TO A SPECIALIST

Many patients with autoimmune hepatitis are under the care of a hepatologist when the diagnosis is made, and we generally encourage management by a hepatologist. However, treatment by a primary care clinician who is familiar with the treatment of autoimmune hepatitis is reasonable. Referral to a hepatologist should be considered for patients who fail to go into remission with glucocorticoid therapy, who worsen despite therapy, or who have cirrhosis at the time of diagnosis. Patients presenting with acute liver failure should immediately be admitted to a hospital, preferably one with a liver transplantation program. (See "Acute liver failure in adults: Etiology, clinical manifestations, and diagnosis" and "Acute liver failure in adults: Management and prognosis".)

                                         

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Literature review current through: Nov 2016. | This topic last updated: Tue Mar 01 00:00:00 GMT+00:00 2016.
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