A recent retrospective study (S Pape et al. Clin Gastroenterol Hepatol 2019; 17: 2068-75) with 451 adults (1978-2017) examined outcomes among patients based on steroid dosing.
A high-dose group (n=281) with initial prednisone/prednisolone dose of ≥0.5 mg/kg/day was compared with a low dose group (n=170) <0.5 mg/kg/day. The low dose group had higher rates of cirrhosis (25.9% vs. 15.3%) but lower median ALT values (7.1 ULN vs. 13.4 ULN) and lower median bilirubin values (48 vs 29 micromol/L).
- There was no difference in rates of transaminase normalization at 1 year: 76.2% vs 77.6%
- Transaminase normalization was lower in patients with cirrhosis 58.1% compared to 70.7% with cirrhosis
- Most patients were receiving low-dose steroids at 6 months, 87.4% in high-dose group compared to 83.5% in low-dose group
- Cumulative steroid dose was lower in low-dose group, with median of 2573 mg over 6 months compared to 3780 mg
Though, not studied in this report, AASLD has recommended use of immunoglobulin levels may help with immunosuppression titration. The editorial (pg 1948-49) notes that budesonide is another alternative for AIH without cirrhosis, though “long-term outcomes including histologic remission and appropriate tapering strategy for budesonide are currently lacking.”
My take: Particularly in patients without severe inflammation, lower steroid doses can be considered for autoimmune hepatitis.
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