Question: A 39 year old female sees you for a presumed diagnosis of type 1 autoimmune hepatitis (+ANA, 1:80). Her anti-smooth muscle Ab and IgG are also elevated. AST is 77 and ALT is 83. Other causes of liver disease have been safely ruled out. She is asymptomatic and has heard bad things about prednisone. What is the most appropriate approach to her management?
A. start prednisone 40 mg QD
B. start budesonide 3 mg TID
C. start budesonide 3 mg TID & azathioprine 50 mg QD
D. wait for AST and ALT to rise, then consider liver biopsy
Answer: The key to this question is understanding the indications for therapeutic intervention for autoimmune hepatitis. Medications should be started when ALT is > 10x the upper limit of normal, or if it is > 5x ULN with histologic evidence of active portal inflammation and interface hepatitis (see histology post: Dec. 14, 2010).
So, performing liver biopsy when aminotransferase levels are higher is appropriate, particularly in this patient who seems anxious about steroids. Prednisone at 40 mg QD is an appropriate dose; as you begin to slowly taper the prednisone, the addition of azathioprine at 50 mg QD is standard (with the intention of reaching 100 mg QD). Only 20% of patients with type 1 AIH will eventually wean from all medications.
Some of you may have opted for budesonide in this case…with good reason. A recent study by Manns et al. (Gastroenterology 2010) showed great clinical efficacy for budesonide in the induction of remission. Fewer side effects are experienced on budesonide, versus prednisone. You can link to this article by clicking on the link below: