Internal Medicine

P1: SBT

0521779407-05 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:49

Autoimmune Hepatitis (AIH) 203

■PSC

■Chronic HBV & HCV infection

■Autoimmune cholangitis

■Cryptogenic chronic active hepatitis

■Wilson disease

■Drug-induced hepatotoxity

management

What to Do First

■Establish firm diagnosis before treatment

■Classify AIH according to type based on serologic tests

General Measures

■Use history, physical exam, liver chemistry, liver biopsy to confirm

AIH & to assess degree of histologic injury

■Decision to treat based on clinical, biochemical, & histologic severity

of illness

■Close monitoring of biochemistry (esp CBC & liver enzymes), side

effects while on medications

specific therapy

Indications

■All patients w/ evidence of hepatic inflammation; may be deferred

for pts w/ mildly increased AST and ALT (<2.5×normal), intolerance

to steroids & azathioprine, inactive &/or decompensated cirrhosis,

severe cytopenias; early treatment prolongs survival (87% at 5 y)

Treatment Options

■Treatment delays, but does not prevent, development of cirrhosis &

end-stage liver disease

■Combination therapy w/ prednisone/azathioprine:

➣Azathioprine daily for 18–24 mo

➣Prednisone daily (80% of patients successfully maintained on

azathioprine as single agent after initial response induced by

steroid therapy)

■Prednisone monotherapy (more steroid-related side effects; indi-

cated in pts w/ azathioprine intolerance or severe cytopenias: high

dose or low dose at onset of therapy dependent upon disease severity

& patient profile

■Overall response∼80%

■Cyclosporine, 6-mercaptopurine, mycophenylate mofetil, tacro-

limus unproven therapies for unresponsive AIH