Management of autoimmune hepatitis: Focus on pharmacologic treatments beyond corticosteroids

Abstract

Core tip: With our review we pretend to describe the non-standard pharmacologic treatments available for autoimmune hepatitis, the indications for its use and the main applications. Also, we pretend to enhance that those alternatives are only available guided by the experience in liver transplant patients and should be only used by experienced centers. The difficult-totreat patients lead to the application of those therapies mainly as salvage treatments.Casal Moura M, Liberal R, Cardoso H, Horta e Vale AM, Macedo G. Management of autoimmune hepatitis: Focus on pharmacologic treatments beyond corticosteroids.

Brazilian society of hepatology recommendations for the diagnosis and management of autoimmune diseases of the liver

“…In one study evaluating mycophenolate mofetil in treatment-naïve patients with AIH, 88% of the subjects had biochemical remission in three months. Partial response, corticosteroid withdrawal were observed, respectively, in 12% and 58% of the patients (54) .Drug-related side effects, particularly nauseas, diarrhea and abdominal pain, were noted in 3% to 33% of the patients (4,48,(50)(51)(52)54) . Despite its safety profile and efficacy, it can not be recommend as first-line therapy due to the paucity of data regarding its use and its higher cost in comparison to azathioprine.…”

“…In these patients, other treatment regimens have been evaluated, including calcineurin inhibitors, either cyclosporin or tacrolimus, mycophenolate mofetil, ursodeoxicholic acid (UDCA), anti-tumor necrosis factor (TNF) alpha agents as well as rituximabe. Some of those agents were also employed in the 10%-15% of subjects, who turn to be intolerant to either azathioprine or corticosteroids, due to the development of side effects (11,13,(48)(49)(50)(51)(52) . There is no evidence-based rational for the use of the aforementioned drugs, currently employed after LT, to treat AIH.…”

“…Improvement of liver enzymers was observed in 93% of the cases. Only 7% of those treated subjects were refractory or intolerant to cyclosporin (11,13,(48)(49)(50)(51)(52) . One study reported significant improvement in AST and/or ALT with good drug tolerance in 19 (nine treatment naïve) adult patients with AIH followed by 26 weeks.…”

“…Cyclosporin was used aiming to achieve trough levels between 100-300 ng/ml (53) . Tacrolimus, on the other hand, have been employed for treatment of AIH since 1995 with improvement in liver enzymes reported in most of the treated patients (13,(48)(49)(50)(51)(52) . Both drugs share similar adverse events, but while diabetes, neurotoxicity, nefrotoxicity, diarrhea, pruritus and alopecia are more frequent with tacrolimus, arterial hypertension, dyslipidemia, hyrsutism and gengival hypertrophy are more commonly seen in cyclosporin-treated patients (48) .…”

Estudo randomizado de cloroquina versus azatioprina, em associação com prednisona, no tratamento da hepatite autoimune

“…Em contrapartida, como a droga não foi adequadamente comparada com o esquema convencional não foi incorporada no tratamento de primeira linha. Os principais efeitos adversos da droga são nefrotoxicidade, dislipidemia, hipertensão arterial sistêmica, hipercalemia, hirsutismo, hipertrofia gengival e indução a malignidades (59,62,63) .…”