Therapeutic options to treat autoimmune hepatitis in 2009

First described in 1950, autoimmune hepatitis (AIH) was the first chronic liver disease with a favorable response to drug therapy and a dismal prognosis when left untreated. In the decades since the first treatment studies, the basic strategy of inducing remission with steroids and azathioprine have not been modified in principle. The main problems are a timely diagnosis before cirrhosis develops, the avoidance of immunosuppressant side effects, nonresponders to standard induction therapy and adherence to therapy. Alternative drugs for immunosuppression have been tested in small series and include transplant immunosuppressants. A large multicenter prospective treatment trial suggests that budesonide may offer an alternative in noncirrhotic AIH patients, capable of minimizing unwanted steroid effects. The ultimate treatment approach is liver transplantation. Although only 4% of transplant patients are transplanted with the diagnosis AIH, the risk for graft loss because of recurrence has to be considered and recurrent AIH treated after transplantation.