Autoimmune hepatitis: treatment

Controlled clinical studies have shown that therapy with corticosteroids prolongs life in the case of severe chronic hepatitis type I.

The benefits of treating autoimmune hepatitis are especially evident in the first two years. Weakness decreases, appetite improves, fever and arthralgia give in to treatment. The menstrual cycle is restored. The levels of bilirubin, y-globulin and the activity of transaminases usually decrease. The changes are so pronounced that on their basis it is possible to establish a diagnosis of autoimmune chronic hepatitis. Histological examination of the liver against the background of treatment reveals a decrease in the activity of the inflammatory process. However, it is not possible to prevent the outcome of chronic hepatitis in cirrhosis.

A liver biopsy should precede the initiation of treatment. If blood clotting disorders serve as a contraindication to this procedure, a biopsy should be performed as early as possible after remission initiated by corticosteroids.

The usual dose of prednisolone is 30 mg / day for 1 week, followed by a decrease to a maintenance dose of 10-15 mg daily. The initial course lasts 6 months. When the remission is reached, which is judged on the basis of the results of clinical and laboratory research and, if possible, a repeated liver biopsy, the dose of the drug is gradually reduced within 2 months. In general, prednisolone therapy is usually continued for about 2-3 years and longer, often all life. Premature cancellation of the drug leads to an exacerbation of the disease. Although usually treatment is resumed after 1-2 months, fatal outcomes are possible.

It is difficult to determine the time of discontinuation of therapy. Perhaps supportive long-term therapy with small doses (less than 10 mg / day) of prednisolone is more preferable. Prednisolone can be used in a slightly higher dose. Prescription of prednisolone in a day is not recommended because of the greater frequency of serious complications and the more rare achievement of remission according to the histological examination.

Complications of corticosteroid therapy include a lunate face, acne, obesity, hirsutism and striae. They are especially undesirable for women. More serious complications are lag in growth in patients younger than 10 years old, diabetes mellitus and severe infections.

Loss of bone mass is detected even at a dose of 10 mg of prednisolone daily and correlates with the duration of therapy. Side effects are rare if the dose of prednisolone does not exceed 15 mg / day. If necessary, exceed this dose, or in case of serious complications, alternative treatment options should be considered.

If no remission occurs at a dose of prednisolone 20 mg / day, azathioprine can be added to therapy at a dose of 50-100 mg / day. It is not suitable for wide use. Long-term (for months or even years) treatment with this drug has obvious drawbacks.

The scheme of taking prednisolone in chronic autoimmune hepatitis

First week

10 mg of prednisolone 3 times a day (30 mg / day)

The second and third weeks

Reduction in the dose of prednisolone to maintenance (10-15 mg / day)

Every month

Clinical examination with hepatic assays

By 6 months

Complete clinical and laboratory examination

Liver biopsy

Complete remission

Gradual withdrawal of prednisolone

Renewal of treatment in case of exacerbation

Absence of remission

Continuation of treatment with prednisolone in the maintenance dose for another 6 months, consideration of the addition of azathioprine (50-100 mg / day)

The maximum dose of 20 mg of prednisolone with 100 mg of azathioprine

At least 2 years: before the disappearance of antinuclear antibodies in the serum before the normalization of bilirubin, y-globulin and transaminase activity, the lack of activity in liver biopsy (usually more than 2 years)

Other indications for the administration of azathioprine are increased cushingoid symptoms, concomitant diseases such as diabetes mellitus, and other side effects associated with the use of prednisolone at doses necessary to achieve remission.

Isolated intake of azathioprine in a high dose (2 mg per 1 kg of body weight) can be prescribed to patients who, with combined treatment, have achieved a complete remission of at least 1 year. Side effects include arthralgia, myelosuppression and increased cancer risk.

Cyclosporine can be used in patients who are resistant to corticosteroid therapy. This toxic drug should be used only as a last resort, with ineffective standard therapy.

Indications for liver transplantation are discussed in cases where corticosteroids failed to achieve remission or when the process is far gone, when complications of cirrhosis develop. Survival after liver transplantation is comparable to that of patients who have achieved remission with corticosteroids. Repeated liver biopsies after transplantation do not reveal a recurrence of autoimmune chronic hepatitis.

[1], [2], [3]