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Autoimmune Hepatitis - Perelman School of Medicine …
Autoimmune Hepatitis Absolute Treatment Indications Clinical Incapacitating symptoms Progression of disease Laboratory AST ? 10 x ULN AST ? 5 x ULN + GG ? 2 x ULN Histology Bridging necrosis Multilobular necrosis Czaja et al. Hepatology 2002;36:479 Krawitt. N Engl J Med 2006;354:54 Autoimmune Hepatitis Relative Treatment Indications Clinical Mild symptoms Laboratory AST 3-9 x ULN AST ? 5 x ULN + GG 2 x ULN Histology Interface hepatitis Active cirrhosis Czaja et al. Hepatology 2002;36:479 Krawitt. N Engl J Med 2006;354:54 Autoimmune Hepatitis No Treatment Clinical Asymptomatic patient Intolerance to prednisone and azathioprine Laboratory AST 3 x ULN Severe cytopenia Histology Portal hepatitis Inactive or decompensated cirrhosis Czaja et al. Hepatology 2002;36:479 Krawitt. N Engl J Med 2006;354:54 Autoimmune Hepatitis Immunosuppressive Therapy Prednisone 30 mg/d x 1 week 20 mg/d x 1 week 15 mg/d x 2 weeks 10 mg/d until endpoint Azathioprine 50 mg/d until endpoint Prednisone alone 60 mg/d x 1 week 40 mg/d x 1 week 30 mg/d x 2 weeks 20 mg/d until endpoint Czaja et al. Hepatology 2002;36:479 Autoimmune Hepatitis Treatment Endpoints Disease remission Relapse after treatment withdrawal Treatment failure Incomplete response Drug toxicity Czaja et al. Hepatology 2002;36:479 Krawitt. N Engl J Med 2006;354:54 Autoimmune Hepatitis Disease Remission Disappearance of symptoms Normalization or near normalization of AST to 2 x ULN GG and bilirubin: normal Minimal or no hepatic inflammation 65% and 80% of patients within 18 months and 3 yrs of initiation of Rx respectively 10 year survival: 90% Czaja et al. Hepatology 2002;36:479 Krawitt. N Engl J Med 2006;354:54 Autoimmune Hepatitis Relapse after Drug Withdrawal Aminotransferases 3 x ULN GG 2g/dL Recurrent inflammation on liver biopsy Risk of relapse 50% at 6 months and 70% at 3 years Prednisone or prednisone + AZA Same regimen as for na?ve patients Long-term low dose prednisone or AZA (2 mg/kg/d) for relapses (goal: AST ? 3x
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