Autoimmune hepatitis: new guidelines, new therapies

Autoimmune hepatitis (AIH) was the first chronic liver disease which responded favorably to drug therapy. It has a dismal prognosis when not treated. Since the original description in 1950 by Waldenström the treatment option initially reported is still practiced today and is the core of the basic therapeutic strategy of inducing remission with steroids and azathioprine. It is important to establish the diagnosis before cirrhosis develops. Later, the avoidance of immunosuppressant side effects, nonresponders to standard induction therapy, and adherence to therapy are among the greatest challenges in treating AIH. Alternative immunosuppressive drugs have been tested in small series and have included commonly used transplant immunosuppressants, albeit with mixed results and many unwanted drug side effects. A recent 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 upon drug treatment failure is liver transplantation. Only 4% of transplant candidates are transplanted for AIH. After liver transplantation, there is a considerable risk for graft loss because of recurrent AIH, and lifelong vigilance and therapeutic attention is important.