Therapy May Not Be Necessary for Autoimmune Hepatitis with No Symptoms

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Therapy May Not Be Necessary for Autoimmune Hepatitis with No

Symptoms

It is not uncommon for patients with autoimmune hepatitis (AIH), a

disease in which the patient's own immune system attacks the liver,

to have no symptoms. Such cases are being diagnosed more frequently

due to the increased practice of administering routine liver enzyme

and antibody tests.

Whether or not to treat asymptomatic AIH remains unclear-- therapy

with immunosuppressants could potentially slow progress of the

disease but involves side effects that are sometimes toxic.

In order to determine if immunosuppressive therapy is indicated when

no symptoms are present, researchers led by Jordan J. Feld, M.D. of

the Departments of Medicine and Pathology at the University Health

Network of the University of Toronto, compared the natural course of

asymptomatic AIH with symptomatic AIH.

The results of the study appear in the July 2005 issue of Hepatology,

the official journal of the American Association for the Study of

Liver Diseases (AASLD), published by Wiley & Sons, Inc.

Hepatology is available online via Wiley InterScience at

http://www.interscience.wiley.com/journal/hepatology

The study included 124 patients diagnosed with AIH at the Toronto

Western Hospital Liver Clinic between 1970 and 2002 – 31 of whom were

asymptomatic. Researchers reviewed the patients' clinical records to

document the presence or absence of symptoms. Patients were

considered asymptomatic if they were free of all symptoms, even non-

specific ones such as fatigue or abdominal pain.

Immunosuppressive therapy was recommended for all symptomatic

patients, while asymptomatic patients were not treated, unless

treatment had already been initiated. Patients who developed symptoms

during the study period were started on immunosuppressive therapy. If

they remained in remission for two years with no relapse the therapy

was discontinued, but it was restarted if the disease recurred off

treatment.

The results of the study indicated that asymptomatic patients had

lower liver enzyme and IgG antibody levels, as well as lower scores

on the hepatic activity index (HAI), which measures liver

inflammation, but otherwise did not differ from patients with

symptoms. Half of the asymptomatic patients ended up receiving

treatment either because it was already started by their physicians

or because they eventually developed symptoms.

" Our data suggest that it may be safe to follow asymptomatic patients

with a strategy to institute immunosuppressive treatment if symptoms

develop over time, " the authors state, although they note that

patients with no symptoms were less likely to respond to treatment

than those that had symptoms.

Notably, the current study also showed that patients who had

cirrhosis when diagnosed had a worse outcome than those that did not,

with a higher incidence of complications or death. Treatment is

normally initiated in asymptomatic patients because it is thought to

prevent the development of cirrhosis, but whether this is the case

remains unclear.

Other studies have been inconclusive in this area and based on the

current study the authors conclude: " Most [asymptomatic] patients

will not develop symptoms during follow-up and they appear to do well

without immunosuppressive therapy at least for as long as they remain

asymptomatic. "