Expert clinical management of autoimmune hepatitis in the real world

R Liberal; Y S de Boer; R J Andrade; G Bouma; G N Dalekos; A Floreani; D Gleeson; Gideon Hirschfield; P Invernizzi; M Lenzi; A W Lohse; G Macedo; P Milkiewicz; B Terziroli; B van Hoek; J M Vierling; M A Heneghan; International Autoimmune Hepatitis Group (IAIHG)

doi:10.1111/apt.13907

Expert clinical management of autoimmune hepatitis in the real world

R Liberal, Y S de Boer, R J Andrade, G Bouma, G N Dalekos, A Floreani, D Gleeson, Gideon Hirschfield, P Invernizzi, M Lenzi, A W Lohse, G Macedo, P Milkiewicz, B Terziroli, B van Hoek, J M Vierling, M A Heneghan, International Autoimmune Hepatitis Group (IAIHG)

Immunology and Immunotherapy

Research output: Contribution to journal › Article › peer-review

50 Citations (Scopus)

Abstract

BACKGROUND: High-quality data on the management of autoimmune hepatitis (AIH) are scarce. Despite published guidelines, management of AIH is still expert based rather than evidence based.

AIM: To survey expert hepatologists, asking each to describe their practices in the management of patients with AIH.

METHODS: A survey questionnaire was distributed to members of the International AIH Group. The questionnaire consisted of four clinical scenarios on different presentations of AIH.

RESULTS: Sixty surveys were sent, out of which 37 were returned. None reported budesonide as a first line induction agent for the acute presentation of AIH. Five (14%) participants reported using thiopurine S-methyltransferase measurements before commencement of thiopurine maintenance therapy. Thirteen (35%) routinely perform liver biopsy at 2 years of biochemical remission. If histological inflammatory activity is absent, four (11%) participants reduced azathioprine, whereas 10 (27%) attempted withdrawal altogether. Regarding the management of difficult-to-treat patients, mycophenolate mofetil is the most widely used second-line agent (n = ~450 in 28 centres), whereas tacrolimus (n = ~115 in 21 centres) and ciclosporin (n = ~112 in 18 centres) are less often reported. One centre reported considerable experience with infliximab, while rescue therapy with rituximab has been tried in seven centres.

CONCLUSIONS: There is a wide variation in the management of patients with autoimmune hepatitis even among the most expert in the field. Although good quality evidence is lacking, there is considerable experience with second-line therapies. Future prospective studies should address these issues, so that we move from an expert- to an evidence- and personalised-based care in autoimmune hepatitis.

Original language	English
Pages (from-to)	723-732
Number of pages	10
Journal	Alimentary Pharmacology & Therapeutics
Volume	45
Issue number	5
Early online date	22 Dec 2016
DOIs	https://doi.org/10.1111/apt.13907
Publication status	Published - Mar 2017

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Liberal, R., de Boer, Y. S., Andrade, R. J., Bouma, G., Dalekos, G. N., Floreani, A., Gleeson, D., Hirschfield, G., Invernizzi, P., Lenzi, M., Lohse, A. W., Macedo, G., Milkiewicz, P., Terziroli, B., van Hoek, B., Vierling, J. M., Heneghan, M. A., & International Autoimmune Hepatitis Group (IAIHG) (2017). Expert clinical management of autoimmune hepatitis in the real world. Alimentary Pharmacology & Therapeutics, 45(5), 723-732. https://doi.org/10.1111/apt.13907

@article{4f875d2de25243cf9fed181f109ce1df,

title = "Expert clinical management of autoimmune hepatitis in the real world",

abstract = "BACKGROUND: High-quality data on the management of autoimmune hepatitis (AIH) are scarce. Despite published guidelines, management of AIH is still expert based rather than evidence based.AIM: To survey expert hepatologists, asking each to describe their practices in the management of patients with AIH.METHODS: A survey questionnaire was distributed to members of the International AIH Group. The questionnaire consisted of four clinical scenarios on different presentations of AIH.RESULTS: Sixty surveys were sent, out of which 37 were returned. None reported budesonide as a first line induction agent for the acute presentation of AIH. Five (14%) participants reported using thiopurine S-methyltransferase measurements before commencement of thiopurine maintenance therapy. Thirteen (35%) routinely perform liver biopsy at 2 years of biochemical remission. If histological inflammatory activity is absent, four (11%) participants reduced azathioprine, whereas 10 (27%) attempted withdrawal altogether. Regarding the management of difficult-to-treat patients, mycophenolate mofetil is the most widely used second-line agent (n = ~450 in 28 centres), whereas tacrolimus (n = ~115 in 21 centres) and ciclosporin (n = ~112 in 18 centres) are less often reported. One centre reported considerable experience with infliximab, while rescue therapy with rituximab has been tried in seven centres.CONCLUSIONS: There is a wide variation in the management of patients with autoimmune hepatitis even among the most expert in the field. Although good quality evidence is lacking, there is considerable experience with second-line therapies. Future prospective studies should address these issues, so that we move from an expert- to an evidence- and personalised-based care in autoimmune hepatitis.",

author = "R Liberal and {de Boer}, {Y S} and Andrade, {R J} and G Bouma and Dalekos, {G N} and A Floreani and D Gleeson and Gideon Hirschfield and P Invernizzi and M Lenzi and Lohse, {A W} and G Macedo and P Milkiewicz and B Terziroli and {van Hoek}, B and Vierling, {J M} and Heneghan, {M A} and {International Autoimmune Hepatitis Group (IAIHG)}",

note = "{\textcopyright} 2016 John Wiley & Sons Ltd.",

year = "2017",

month = mar,

doi = "10.1111/apt.13907",

language = "English",

volume = "45",

pages = "723--732",

journal = "Alimentary Pharmacology & Therapeutics",

issn = "0269-2813",

publisher = "Wiley",

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Liberal, R, de Boer, YS, Andrade, RJ, Bouma, G, Dalekos, GN, Floreani, A, Gleeson, D, Hirschfield, G, Invernizzi, P, Lenzi, M, Lohse, AW, Macedo, G, Milkiewicz, P, Terziroli, B, van Hoek, B, Vierling, JM, Heneghan, MA & International Autoimmune Hepatitis Group (IAIHG) 2017, 'Expert clinical management of autoimmune hepatitis in the real world', Alimentary Pharmacology & Therapeutics, vol. 45, no. 5, pp. 723-732. https://doi.org/10.1111/apt.13907

TY - JOUR

T1 - Expert clinical management of autoimmune hepatitis in the real world

AU - Liberal, R

AU - de Boer, Y S

AU - Andrade, R J

AU - Bouma, G

AU - Dalekos, G N

AU - Floreani, A

AU - Gleeson, D

AU - Hirschfield, Gideon

AU - Invernizzi, P

AU - Lenzi, M

AU - Lohse, A W

AU - Macedo, G

AU - Milkiewicz, P

AU - Terziroli, B

AU - van Hoek, B

AU - Vierling, J M

AU - Heneghan, M A

AU - International Autoimmune Hepatitis Group (IAIHG)

PY - 2017/3

Y1 - 2017/3

N2 - BACKGROUND: High-quality data on the management of autoimmune hepatitis (AIH) are scarce. Despite published guidelines, management of AIH is still expert based rather than evidence based.AIM: To survey expert hepatologists, asking each to describe their practices in the management of patients with AIH.METHODS: A survey questionnaire was distributed to members of the International AIH Group. The questionnaire consisted of four clinical scenarios on different presentations of AIH.RESULTS: Sixty surveys were sent, out of which 37 were returned. None reported budesonide as a first line induction agent for the acute presentation of AIH. Five (14%) participants reported using thiopurine S-methyltransferase measurements before commencement of thiopurine maintenance therapy. Thirteen (35%) routinely perform liver biopsy at 2 years of biochemical remission. If histological inflammatory activity is absent, four (11%) participants reduced azathioprine, whereas 10 (27%) attempted withdrawal altogether. Regarding the management of difficult-to-treat patients, mycophenolate mofetil is the most widely used second-line agent (n = ~450 in 28 centres), whereas tacrolimus (n = ~115 in 21 centres) and ciclosporin (n = ~112 in 18 centres) are less often reported. One centre reported considerable experience with infliximab, while rescue therapy with rituximab has been tried in seven centres.CONCLUSIONS: There is a wide variation in the management of patients with autoimmune hepatitis even among the most expert in the field. Although good quality evidence is lacking, there is considerable experience with second-line therapies. Future prospective studies should address these issues, so that we move from an expert- to an evidence- and personalised-based care in autoimmune hepatitis.

AB - BACKGROUND: High-quality data on the management of autoimmune hepatitis (AIH) are scarce. Despite published guidelines, management of AIH is still expert based rather than evidence based.AIM: To survey expert hepatologists, asking each to describe their practices in the management of patients with AIH.METHODS: A survey questionnaire was distributed to members of the International AIH Group. The questionnaire consisted of four clinical scenarios on different presentations of AIH.RESULTS: Sixty surveys were sent, out of which 37 were returned. None reported budesonide as a first line induction agent for the acute presentation of AIH. Five (14%) participants reported using thiopurine S-methyltransferase measurements before commencement of thiopurine maintenance therapy. Thirteen (35%) routinely perform liver biopsy at 2 years of biochemical remission. If histological inflammatory activity is absent, four (11%) participants reduced azathioprine, whereas 10 (27%) attempted withdrawal altogether. Regarding the management of difficult-to-treat patients, mycophenolate mofetil is the most widely used second-line agent (n = ~450 in 28 centres), whereas tacrolimus (n = ~115 in 21 centres) and ciclosporin (n = ~112 in 18 centres) are less often reported. One centre reported considerable experience with infliximab, while rescue therapy with rituximab has been tried in seven centres.CONCLUSIONS: There is a wide variation in the management of patients with autoimmune hepatitis even among the most expert in the field. Although good quality evidence is lacking, there is considerable experience with second-line therapies. Future prospective studies should address these issues, so that we move from an expert- to an evidence- and personalised-based care in autoimmune hepatitis.

U2 - 10.1111/apt.13907

DO - 10.1111/apt.13907

M3 - Article

C2 - 28004405

SN - 0269-2813

VL - 45

SP - 723

EP - 732

JO - Alimentary Pharmacology & Therapeutics

JF - Alimentary Pharmacology & Therapeutics

IS - 5

ER -

Expert clinical management of autoimmune hepatitis in the real world

Abstract

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