This protocol addresses autoimmune hepatitis (AIH) in patients with concurrent cirrhosis of the liver who have not reached biochemical remission on first-line corticosteroid-based therapy.
Autoimmune hepatitis with cirrhosis of the liver. Management in this population requires particular caution in agent selection — not all therapies appropriate in non-cirrhotic AIH are suitable here. Specifically, budesonide is not recommended for patients with AIH who have cirrhosis.
Standard first-line management for AIH with cirrhosis combines prednisone or prednisolone with azathioprine. This second-line protocol applies when that regimen results in treatment failure, incomplete response, or drug intolerance — specifically, when normalization of serum ALT, AST, and IgG levels (biochemical remission) is not achieved.
When first-line corticosteroid-based therapy has not produced adequate biochemical improvement, an alternative immunosuppressive strategy is taken. Mycophenolate mofetil is among the agents considered at this stage. The full structured regimen — including all options and decision criteria — is available in the complete protocol.
Achievement and maintenance of biochemical remission: normalization of serum AST, ALT, and IgG levels.
DOI: 10.1002/hep.31065
For children and adults with AIH who have cirrhosis or who present with acute severe AIH, the AASLD suggests that budesonide not be used (conditional recommendation, very low certainty).
In children or adults with AIH who have treatment failure, incomplete response, or drug intolerance to first-line agents, the AASLD suggests the use of MMF or TAC to achieve and maintain biochemical remission (conditional recommendation, low certainty).
Based on a superior ease of use and side-effect profile, the AASLD suggests a trial of MMF over TAC as the initial second-line agent in patients with AIH (conditional recommendation, very low certainty).
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