title: Management of autoimmune hepatitis: Focus on pharmacologic treatments beyond corticosteroids.
abstract: In autoimmune hepatitis, patients who are intolerant or with toxicity experience, non-responders, relapsers or refractory are challenging. Non-standard drugs are being tried to preemptively avoid corticosteroid-related side effects. Prognosis and quality of life of life rely on treatment optimization. Recently, emergence of powerful immunosuppressive agents, mainly from liver transplantation, challenged the supremacy of the corticosteroid regime and promise greater immunosuppression than conventional medications, offer site-specific actions and satisfactory patient tolerance. Successes in experimental models of related diseases have primed these molecular interventions. We performed a literature review on alternative treatments. Azatioprine intolerance is the principal indication for mycophenolate use but it can be used as a front-line therapy. Cyclosporine A and tacrolimus have been tested for non-responders or relapsers. Rituximab may be used as salvage therapy. Anti-tumor necrosis factor-alpha agents may be used for incomplete responses or non-responders. Methotrexate is possibly an alternative for induction of remission and maintenance in refractory patients. Cyclophosphamide has been included in the induction regimen with corticosteroids. Ursodeoxycholic acid action is mainly immunomodulatory. Non-standard treatments are coming slowly to the attention, but its use should be cautious performed by experienced centers.
authors.affiliation: Marta Casal Moura, Serviço de Medicina Interna, Centro Hospitalar de São João, E.P.E., Porto 4200-319, Portugal.
authors.forename: Marta
authors.initials: M
authors.lastname: Casal Moura
authors.affiliation: Marta Casal Moura, Serviço de Medicina Interna, Centro Hospitalar de São João, E.P.E., Porto 4200-319, Portugal.
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Liberal
authors.affiliation: Marta Casal Moura, Serviço de Medicina Interna, Centro Hospitalar de São João, E.P.E., Porto 4200-319, Portugal.
authors.forename: Hélder
authors.initials: H
authors.lastname: Cardoso
authors.affiliation: Marta Casal Moura, Serviço de Medicina Interna, Centro Hospitalar de São João, E.P.E., Porto 4200-319, Portugal.
authors.forename: Ana Maria
authors.initials: AM
authors.lastname: Horta E Vale
authors.affiliation: Marta Casal Moura, Serviço de Medicina Interna, Centro Hospitalar de São João, E.P.E., Porto 4200-319, Portugal.
authors.forename: Guilherme
authors.initials: G
authors.lastname: Macedo
keywords: Autoimmune hepatitis; Azathioprine intolerance; Difficult-to-treat patients; Immunosuppression; Pharmacologic non-standard treatment; Salvage therapy