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 NICE CG165. This is to assess the risk of hepatitis B reactivation and offer prophylaxis if indicated NICE CG165.
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 NICE CG165.
- 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 ].
Key References
- CKS - Hepatitis B
- CG165 - Hepatitis B (chronic): diagnosis and management
- CKS - Non-alcoholic fatty liver disease (NAFLD)
- NG49 - Non-alcoholic fatty liver disease (NAFLD): assessment and management
- (European Association for the Study of the Liver, 2015): EASL Clinical Practice Guidelines: Autoimmune hepatitis.
- (Mack et al., 2020): Diagnosis and Management of Autoimmune Hepatitis in Adults and Children: 2019 Practice Guidance and Guidelines From the American Association for the Study of Liver Diseases.
- (Gleeson et al., 2025): British Society of Gastroenterology guidelines for diagnosis and management of autoimmune hepatitis.