Initial management of adults with autoimmune hepatitis who do not have acute liver failure or cirrhosis

ALT: alanine aminotransferase; AST: aspartate aminotransferase; HAV: hepatitis A virus; HBV: hepatitis B virus; IgG: immunoglobulin G; TPMT: thiopurine methyltransferase.

* For thiopurine therapy, we typically use azathioprine. For patients with mild adverse effects (eg, gastrointestinal disturbances) related to azathioprine, we may switch to 6-mercaptopurine at one-half of the azathioprine dose.

¶ For most adults, we initiate prednisone 40 to 60 mg daily. After one to two weeks, we taper prednisone by 5 to 10 mg every one to two weeks to a dose of 20 mg daily. Next, we taper prednisone by 5 mg every one to two weeks to a target dose of 10 mg daily. Patients usually remain at this dose until achieving complete biochemical response. Oral prednisolone may be substituted for prednisone using the same dosing regimen. For patients with mild disease (asymptomatic patients with aminotransferase levels <10 times the upper limit of normal), we typically initiate prednisone at a lower dose (20 to 30 mg per day).

Δ For all patients, laboratory monitoring includes aminotransferases (AST, ALT), IgG level, and total bilirubin. For patients on a thiopurine, complete blood count and amylase are also measured.

◊ Complete biochemical response is the normalization of serum aminotransferases (AST, ALT) and IgG (ie, levels below the upper limit of normal).