Difficult treatment decisions in autoimmune hepatitis

Table 4 Difficult treatment decisions after conventional corticosteroid therapy

Problem	Response
Empirical salvage drugs	Consider cyclosporine (5-6 mg/kg per day)[144-150] or tacrolimus (4 mg bid)[21,22,151,152] if progressive disease on conventional treatment
	Consider mycophenolate mofetil (1 g bid) if corticosteroid or azathioprine intolerance[23,24,153-159]
	Consider budesonide (3 mg tid) as frontline therapy if mild disease or if azathioprine maintenance insufficient after relapse or incomplete response[25,26]
	Complete benefit-risk and cost analyses before use[160,161]
	Empirical trial must not supersede liver transplantation[55,130,131]
Liver transplantation	Consider if acute severe (fulminant) presentation unresponsive or worse within 2 wk of conventional treatment[52,53,56,57]
	Consider if treatment dependent ≥ 3 yr and features of decompensation develop (ascites, encephalopathy or variceal bleeding)[130]
	Consider if failure to conventional therapy and MELD score ≥ 15 points[52,131,132]
Elderly patients (aged ≥ 60 yr)	Restrict conventional therapy to combination regimen[124]
	Limit initial treatment to ≤ 24 mo[125]
	Institute azathioprine maintenance therapy (2 mg/kg per day) if initial response is incomplete at 24 mo[124]
	Consider liver transplantation if features of decompensation emerge[132]
Pregnant patients	Counsel regarding risks of prematurity and infant mortality[162-167]
	Institute high-risk obstetrical care[30,162]
	Avoid azathioprine if possible[165,168]
	Reduce doses of prednisone to lowest levels to stabilize if not resolve laboratory indices[169]
	Reestablish conventional prednisone doses prior to delivery[169]
	Be alert to post-partum flares[163,164,169]