Expert clinical management of autoimmune hepatitis in the real world

Aliment Pharmacol Ther. 2017 Mar;45(5):723-732. doi: 10.1111/apt.13907. Epub 2016 Dec 22.


Background: High-quality data on the management of autoimmune hepatitis (AIH) are scarce. Despite published guidelines, management of AIH is still expert based rather than evidence based.

Aim: To survey expert hepatologists, asking each to describe their practices in the management of patients with AIH.

Methods: A survey questionnaire was distributed to members of the International AIH Group. The questionnaire consisted of four clinical scenarios on different presentations of AIH.

Results: Sixty surveys were sent, out of which 37 were returned. None reported budesonide as a first line induction agent for the acute presentation of AIH. Five (14%) participants reported using thiopurine S-methyltransferase measurements before commencement of thiopurine maintenance therapy. Thirteen (35%) routinely perform liver biopsy at 2 years of biochemical remission. If histological inflammatory activity is absent, four (11%) participants reduced azathioprine, whereas 10 (27%) attempted withdrawal altogether. Regarding the management of difficult-to-treat patients, mycophenolate mofetil is the most widely used second-line agent (n = ~450 in 28 centres), whereas tacrolimus (n = ~115 in 21 centres) and ciclosporin (n = ~112 in 18 centres) are less often reported. One centre reported considerable experience with infliximab, while rescue therapy with rituximab has been tried in seven centres.

Conclusions: There is a wide variation in the management of patients with autoimmune hepatitis even among the most expert in the field. Although good quality evidence is lacking, there is considerable experience with second-line therapies. Future prospective studies should address these issues, so that we move from an expert- to an evidence- and personalised-based care in autoimmune hepatitis.

MeSH terms

  • Azathioprine / therapeutic use
  • Biopsy
  • Budesonide / therapeutic use
  • Cyclosporine / therapeutic use
  • Health Care Surveys
  • Hepatitis, Autoimmune / drug therapy*
  • Humans
  • Immunosuppressive Agents / therapeutic use*
  • Methyltransferases / metabolism
  • Mycophenolic Acid / therapeutic use
  • Rituximab / therapeutic use
  • Tacrolimus / therapeutic use


  • Immunosuppressive Agents
  • Rituximab
  • Budesonide
  • Cyclosporine
  • Methyltransferases
  • thiopurine methyltransferase
  • Mycophenolic Acid
  • Azathioprine
  • Tacrolimus