What are the current guidelines for the management of autoimmune hepatitis in adults, including pharmacological treatments?

The management of autoimmune hepatitis (AIH) in adults primarily involves immunosuppressive therapy to induce and maintain remission [ (European Association for the Study of the Liver, 2015), (Mack et al., 2020), (Gleeson et al., 2025) ]. Before initiating immunosuppressive therapy for autoimmune diseases, including AIH, it is crucial to perform tests for hepatitis B surface antigen (HBsAg), antibody to hepatitis B core antigen (anti-HBc), plasma or serum HBV DNA level, and ALT ². This is to assess the risk of hepatitis B reactivation and offer prophylaxis if indicated ².

Pharmacological Treatments:

• First-line Therapy: The cornerstone of treatment for AIH is corticosteroids, typically prednisolone, often combined with an immunosuppressant such as azathioprine [ (European Association for the Study of the Liver, 2015), (Mack et al., 2020), (Gleeson et al., 2025) ]. The aim is to achieve biochemical remission, indicated by normalisation of liver enzymes (e.g., ALT, AST) [ (European Association for the Study of the Liver, 2015), (Mack et al., 2020) ].
• Corticosteroids: Prednisolone is commonly used, with initial doses varying depending on disease severity, followed by a gradual taper once remission is achieved [ (European Association for the Study of the Liver, 2015), (Mack et al., 2020) ].
• Azathioprine: This is often introduced concurrently with corticosteroids to allow for a lower corticosteroid dose and to maintain remission, thereby reducing corticosteroid-related side effects [ (European Association for the Study of the Liver, 2015), (Mack et al., 2020) ]. Patients should be screened for thiopurine methyltransferase (TPMT) deficiency before starting azathioprine to prevent severe myelosuppression [ (Mack et al., 2020) ].
• Second-line and Rescue Therapies: For patients who do not respond to first-line treatment, cannot tolerate it, or experience significant side effects, alternative immunosuppressants may be considered [ (European Association for the Study of the Liver, 2015), (Mack et al., 2020) ]. These can include mycophenolate mofetil (MMF), ciclosporin, tacrolimus, or budesonide (especially for non-cirrhotic patients) [ (European Association for the Study of the Liver, 2015), (Mack et al., 2020), (Gleeson et al., 2025) ]. Rituximab or other B cell-depleting therapies are also mentioned in the context of immunosuppressive therapy, requiring specific HBV prophylaxis if the patient is HBsAg negative and anti-HBc positive ².
• Treatment Duration: Treatment is typically long-term, often lifelong, as relapse is common if therapy is discontinued [ (European Association for the Study of the Liver, 2015), (Mack et al., 2020) ]. Decisions regarding treatment withdrawal should be made cautiously and only after sustained remission, with close monitoring for relapse [ (European Association for the Study of the Liver, 2015) ].

Monitoring: Regular monitoring of liver biochemistry, full blood count, and drug levels (for certain immunosuppressants) is essential to assess treatment response, detect side effects, and adjust dosages [ (European Association for the Study of the Liver, 2015), (Mack et al., 2020) ].