Autoimmune hepatitis remains a disease with an unpredictable and in some instances, unresolving course. As noted before, the AASLD recommends induction/initial therapy with Prednisone alone or the combination of Azathioprine to Prednisone. Azathioprine monotherapy is only recommended for maintenance therapy after initial therapy. The major advantage of the dual therapy is to mitigate the side effects of steroids especially in the long term as this is a disease that in many cases needs some form of maintenance treatment for continued remission. On the other hand, Azathioprine and its drug metabolite 6-Mercaptopurine are not without their side effects. They should be used with great caution in patients with pre existing cytopenias, malignancy or thiopirine methyltransferase (TPMT) deficiency. Such patients are typically considered for monotherapy with Prednisone.
The AASLD recommends that treatment be instituted in the following situations [3
]: 1), serum alanine aminotransferase (ALT) or serum aspartate aminotransferase (AST) level greater than 10-fold the upper limit of normal; 2), serum ALT, AST, or gamma globulin level greater than twice the upper limit of normal if any of the following are present: (1), symptomatic patients; (2), an elevated conjugated bilirubin or, in the case of an ALT or AST that is twice the upper limit of normal, an elevated gamma globulin level, even if less than twice the upper limit of normal; (3), interface hepatitis on biopsy; (4), histologic features of bridging necrosis or multiacinar necrosis; (5), cirrhosis with any degree of inflammation on biopsy; (6), children with autoimmune hepatitis.
The risks of drug treatment and the possibility of deleterious side effects needs to be cautiously weighed against the benefits of the same in asymptomatic patients with normal serum aminotransferase/gamma globulin levels and evidence of minimal cirrhotic progression despite strong suspicion of autoimmune hepatitis. Nonetheless, such patients need to be placed under close surveillance and treatment started immediately following the advent of abnormal liver enzymes or gamma globulin levels. Close surveillance should also include adequate diet and exercise to prevent obesity and possible concomitant non alcoholic fatty liver disease, proper hepatitis A and B vaccination to prevent concomitant or super infection with viral hepatitis, abstinence from alcohol to prevent alcoholic liver disease and a high importance placed on safe sexual practices. Patients presenting with acute/Fulminant hepatitis secondary to autoimmune hepatitis need to be referred to a liver transplant center for further evaluation and management. The above retrospective study only seeks to assess and compare the efficacy of recommended regimens of the induction phase in the treatment of Autoimmune Hepatitis [10
]. Obviously, the goal in treating these patients is to achieve long lasting remission but this is easier said than done. As mentioned before, this is a disease that is as unpredictable as it is severe if not carefully attended to. Our study results show that better efficacy was achieved in the induction phase using a combination of Prednisone and Azathioprine from the beginning of the treatment course. The relatively low number of patients and the fact that the study was performed in a single center are probable limitations. However, we are of the opinion that our results could serve as foundation for further research which can lead to better defined guidelines in the treatment of Autoimmune Hepatitis.