Difficult treatment decisions in autoimmune hepatitis

Table 3 Difficult treatment decisions during conventional corticosteroid therapy

Problem	Response
Determining treatment end point	Continue conventional therapy until normal serum AST, ALT, bilirubin and γ-globulin levels and normal liver tissue or inactive cirrhosis (ideal end point)[119-121]
	Continue conventional therapy until serum AST ≤ 2 times ULN, bilirubin and γ-globulin levels normal, and portal hepatitis or minimally active cirrhosis (satisfactory end point)[11,54,55]
	Decrease dose of culprit drug or discontinue its use if side effects emerge (drug toxicity end point)[13,55]
	Limit conventional corticosteroid treatment of patients aged ≥ 60 yr if an ideal or satisfactory end point has not been achieved ≤ 24 mo (incomplete response end point)[11,19,124,125]
Relapse after drug withdrawal	Institute original therapy until clinical and laboratory resolution, then increase azathioprine dose to 2 mg/kg per day as dose of prednisone is withdrawn[126,127]
	Continue daily azathioprine in fixed dose indefinitely[126,127]
	Use low dose prednisone ( ≤ 10 mg/d) if severe cytopenia (leukocyte counts < 2.5 × 109/L or platelet counts < 50 × 109/L) or other azathioprine intolerances[13,55]
	Use low dose prednisone (2.5-5 mg/d) to supplement azathioprine maintenance if abnormal serum AST level[55,128]
Treatment failure	Prednisone, 60 mg/d, or prednisone, 30 mg/d, in combination with azathioprine, 150 mg/d, for at least 1 mo, then dose reductions by 10 mg for prednisone and 50 mg for azathioprine each month of laboratory improvement until conventional doses reached[54,55,129]
	Evaluate for liver transplantation if minimal criteria for listing (MELD ≥ 15 points) are met[130-132]
Incomplete response	Azathioprine (2 mg/kg per day) indefinitely after corticosteroid withdrawal[54,55,127]
	Low-dose prednisone ( ≤ 10 mg/d) if azathioprine intolerance[54,55,128]
	Adjustments to maintain serum AST level ≤ 3 times ULN[55,133]

MELD: Model of end stage liver disease; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase.