AIH Therapy: Beyond First‑Line

The purpose of the article is to review treatment options for patients with AIH for whom first-line therapy is not successful. We outline recommended approaches for providers and new therapies on the horizon.

Budesonide, while advantageous in some respects, may not be as effective as predniso(lo)ne. Mycophenolate mofetil is most effective in the setting of azathioprine intolerance and less effective when the response to azathioprine has been inadequate. Infliximab is the biologic agent with the most evidence for use in AIH. Clinical trials studying interleukin 2, regulatory T cells, inhibitors of BAFF signaling, and immunoproteasome inhibitors have been initiated but more research is needed, particularly in Black people, Indigenous people, and People of Color.

While multiple agents have been reported as second- or third-line therapies, the evidence is limited. Future research will require multicenter collaboration and should explore therapeutics supported by molecular studies.