Advancements in autoimmune hepatitis management: Perspectives for future guidelines

Area of Science:

• Hepatology and Immunology
• Gastroenterology
• Pharmacology

Background:

• First-line treatment for autoimmune hepatitis (AIH) typically involves prednisone or prednisolone, alone or with azathioprine (AZA).
• Budesonide is an optional first-line treatment, particularly for non-cirrhotic patients, though study designs may favor its efficacy.
• Mycophenolate mofetil (MMF) is recommended for AZA-intolerant patients, but evidence is limited, mainly from case series.

Discussion:

• Real-world data suggest prednisone may yield higher complete biochemical response (CBR) rates than budesonide when equivalent doses are used.
• MMF has shown superiority over AZA in renal transplant contexts, with higher CBR, lower failure rates, and better tolerance.
• Current treatment guidelines for AIH may need revision based on emerging comparative data favoring MMF over AZA.

Key Insights:

• Prednisone demonstrated higher CBR rates compared to budesonide in a recent real-life study.
• MMF exhibits potential advantages over AZA, including improved efficacy and tolerability, warranting further investigation in AIH.
• Lifelong AZA maintenance therapy carries risks like skin cancer and lymphoma, highlighting the need for safer alternatives.

Outlook:

• Prospective trials are crucial to evaluate treatment cessation strategies based on histological or biochemical criteria.
• Further research is needed to validate promising results from single-center studies on chloroquine diphosphate for relapse reduction.
• Controlled trials are essential for assessing second-line therapies such as tacrolimus, rituximab, and infliximab in AIH management.