This protocol addresses the first-line management of acute severe autoimmune hepatitis in patients presenting with jaundice and a coagulopathy in the range of INR 1.5–2, with no hepatic encephalopathy and no previously recognised liver disease — a specific, high-acuity subgroup requiring a structured treatment trial.
The patient presents with acute severe autoimmune hepatitis accompanied by jaundice, an INR above 1.5 but below 2, and no encephalopathy. This presentation — distinct from acute liver failure — qualifies for a first-line pharmacological treatment trial rather than immediate transplant evaluation.
The standard approach involves a trial of glucocorticoid therapy. The specific agent used, its dosing strategy, the conditions under which the regimen may be adjusted, and what to do after a biochemical response are all laid out in the full protocol — the partial description here is intentional.
Certain agents used in other autoimmune hepatitis settings are not appropriate in this acute severe presentation; the protocol specifies which and why.
The primary target is improvement in laboratory markers of liver inflammation and function — especially serum aminotransferases and bilirubin — without clinical deterioration. Response is assessed within 1–2 weeks of initiating therapy, and the rapidity of that response is the most important indicator of outcome.
Acute severe AIH Jaundice, INR > 1.5 < 2, no encephalopathy; no previously recognized liver disease.
Patients with acute severe AIH should receive a treatment trial with prednisone or prednisolone alone, whereas patients with AIH and ALF should be evaluated directly for LT.
Glucocorticoid therapy (usually prednisone or prednisolone alone, 0.5-1 mg/kg daily in adults and up to 2 mg/kg in children) has been effective in 20%-100% of patients with acute severe AIH and has not been associated with an increase in sepsis.
The role of budesonide as first-line treatment in acute severe AIH or ALF is unknown, and thus it is not recommended in these settings.
Patients with acute severe AIH who do not improve laboratory tests or clinically worsen within 1-2 weeks of glucocorticoid therapy should be evaluated for LT.
The rapidity of response to treatment is the most important index of outcome, and the serum aminotransferase levels should improve within 2 weeks.
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