Autoimmune Hepatitis Medication

Updated: Oct 20, 2021
  • Author: David C Wolf, MD, FACP, FACG, AGAF, FAASLD; Chief Editor: BS Anand, MD  more...
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Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Treatment with corticosteroids and azathioprine is the cornerstone of achieving remission. Initiating azathioprine with prednisone at the beginning of treatment enables a faster decrease in the prednisone dose.

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Corticosteroids

Class Summary

Corticosteroids induce immunosuppression through a number of mechanisms. Most notably, they help to block T-cell-derived and antigen-presenting cell (APC)-derived cytokine expression. [86] Corticosteroids can suppress lymphocyte activity and decrease antibody production. They can also suppress the production of prostaglandins and leukotrienes, helping to reduce inflammation.

The rapid institution of treatment with high-dose corticosteroids may rescue patients whose disease ultimately would have progressed to either acute liver failure or cirrhosis. Long-term treatment with corticosteroids has been shown to improve the chances for survival significantly.

Prednisone

Prednisone is an immunosuppressant for the treatment of autoimmune disorders. It may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear neutrophil (PMN) activity. It stabilizes lysosomal membranes and also suppresses lymphocytes and antibody production.

Prednisolone

Prednisolone decreases autoimmune reactions, possibly by suppressing key components of the immune system. It may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

Budesonide (Entocort EC, Ortikos, Uceris)

Budesonide is an anti-inflammatory corticosteroid with potent glucocorticoid activity but weak mineralocorticoid activity. It offers the promise of fewer steroid-specific side effects. Because of its high first-pass metabolism, the majority of the orally absorbed drug does not reach the systemic circulation.

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Immunosuppressants

Azathioprine (Imuran, Azasan)

Azathioprine antagonizes purine metabolism and helps to block DNA replication in T and B lymphocytes. [108] This, in turn, results in decreased autoimmune activity. Azathioprine has been used in the treatment of autoimmune hepatitis since the early 1970s. [109]

Mycophenolate (CellCept, MMF, Myfortic)

Mycophenolate mofetil and mycophenolic acid inhibit the production of inosine phosphate dehydrogenase and the production of guanosine nucleotides. This, in turn, leads to the blockade of DNA replication in T and B lymphocytes. [108] Mycophenolate is utilized in patients who are intolerant to azathioprine, as well as in patients who had either an incomplete response or a treatment failure after combination therapy with corticosteroids plus azathioprine. [78]

Cyclosporine (Gengraf, Sandimmune, Neoral)

Calcineurin stimulates the expression of interleukin-2 (IL-2)—amongst other cytokines—by T lymphocytes. IL-2, in turn, stimulates the proliferation of T lymphocytes. By inhibiting calcineurin’s function, both cyclosporine and tacrolimus inhibit the production of IL-2, with resulting suppression of T cell-mediated immunity. The dosing of both drugs is based upon the patient’s body weight. Most experts recommend the routine follow-up of patients’ trough drug levels.

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