Management of Nonresponders to First-line Drugs in Autoimmune Hepatitis
In autoimmune hepatitis (AIH), not all patients respond adequately to first-line treatment. When patients do not respond to or cannot tolerate the initial treatment, alternative management strategies are required, such as second-line therapies and therapies in the pipeline (third-line). This second-line therapy is also known as salvage therapy. Common options include:
- Mycophenolate mofetil (MMF): It is an alternative for patients who are intolerant to azathioprine with a response rate of 58% to 61%. This works by inhibiting purine biosynthesis and exhibiting an antiproliferative effect on T- and B-cells.
- Tacrolimus: This calcineurin inhibitor might be much better than MMF for nonresponder. The response rate of this drug is 59%. This works by suppressing IL-2 synthesis, thereby decreasing T-cell proliferation and differentiation. In severe cases or when conventional immunosuppressive therapy fails, biological agents such as rituximab (anti-CD20 monoclonal antibody) can be used. These agents target B-cells to help control the autoimmune response. Studies have shown that rituximab improves AIH activity by significantly decreasing OT/PT, and serum IgG at 1 month and increasing serum albumin levels. These studies have shown that rituximab is:
- Safe and effective
- Validates the utility of B-cells depletion therapy in refractory AIH
- PRCTs for licensing indications.
Dr. Vivek Saraswat
Dr. Vivek Saraswat is an Assistant Professor at MAIP, Jaipur.
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