The Challenges of Treating Autoimmune Hepatitis

Autoimmune hepatitis often responds well to steroid therapy but identifying the disease and the best approach to management is filled with complexities, said Paul Martin, MD, professor of medicine, and division chief of Hepatology at Leonard M. Miller School of Medicine, University of Miami, who spoke this week at a joint conference of the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy in Coronado, California.

Autoimmune hepatitis has characteristic clinical, serological, and histological features but many tests used in its medical management are not specific for the condition, noted Martin.

“We need to keep an open mind when we are evaluating patients with autoimmune hepatitis,” said Martin, speaking about the difficulties of diagnosing the condition.

The disease is steroid responsive, so a revised diagnosis may be in order if a patient does not respond to therapy within a few weeks.

A helpful tool is the fairly recent development of diagnostic criteria for autoimmune hepatitis, which assigns points based on the presence of a number of factors, including auto antibodies. It provides a useful checklist when evaluating a patient, said Martin.

In treating the condition, the goal is to prevent progression of liver disease, relieve fatigue and other symptoms, and achieve normalized liver chemistries.

“We’re trying to achieve a histological remission,” said Martin. “However, there’s often a disconnect between the liver test and what’s going on in the liver biopsy. So liver tests get better first and the biopsy may lag behind by many months.”

Patients, too, may feel better before the improvement shows up in lab tests, so it’s best to repeat testing before stopping steroid therapy, said Martin.

About two-thirds of patients have prompt remission when treated with traditional steroid therapy while a smaller percent experience drug toxicity and treatment failure, said Martin. Though doctors want to use potent drugs to treat autoimmune hepatitis, they must also try to minimize the challenging side effects of steroids, he said.

One of the challenges in treating autoimmune hepatitis is sorting out overlapping syndromes and deciding what therapy works best. So expect continuing uncertainties, said Martin.

“I think what we need to do is to take the pragmatic approach and treat that which appears to be the predominant disorder,” he said.

Martin said therapeutic opportunities to treat autoimmune hepatitis are expanding and included a discussion on alternative drug therapies. “These are complicated liver diseases but they are gratifying to recognize and treat.”

Martin serves on advisory committees or review panels of several pharmaceutical companies, including Salix Pharmaceuticals, Merk & Co. and Genentech.