Autoimmune hepatitis treatment in the elderly: A systematic review

Abstract

BACKGROUND Autoimmune hepatitis (AIH) is a rare chronic inflammatory liver disease with a high risk of progression to liver cirrhosis. The initial treatment for AIH usually includes a steroid, with or without azathioprine. AIH can present at any age; however, the most effective and safe induction treatment for AIH in the elderly remains unclear. AIM To systematically review available data on both effectiveness and safety of AIH treatments in elderly subjects. METHODS To identify studies on AIH induction treatment in elderly patients (≥ 60 years of age), an electronic research was performed (PubMed, EMBASE and Cochrane Library databases) until February 2019. Eligible studies were selected through screening of titles and abstracts, followed by full-text critical evaluation. After risk of bias assessment, data on study designs, interventions, and outcomes were extracted and reviewed. RESULTS Among the 1736 retrieved papers, 15 studies were selected. Out of them, eight studies were excluded because of a critical risk of bias. The remaining seven studies included 789 patients and out of them 239 subjects were elders. First-line treatment was a steroid either alone or in combination with azathioprine in most patients (87.6%) and only one study investigated the effect of combined steroid and mycophenolate mofetil therapy. Standard therapy was effective in inducing remission in the elderly. Moreover, treatment failure and relapses occurred less often in the elderly compared to younger people. CONCLUSION Treatment of AIH is challenging in elderly patients. This systematic review confirms the efficacy and safety of standard induction treatment for AIH in the elderly. Available evidence is insufficient to draw any conclusion on the effect of novel AIH treatments in elderly subjects.

Autoimmune hepatitis in patients aged 70 years or older: Disease characteristics, treatment response and outcome

“…However, the response rates as shown by our study suggest that even AIH patients ≥70 y can be candidates for immunosuppression. In this context, a recent meta‐analysis showed that standard therapy was effective in inducing remission in the older, while treatment failure and relapses were less often compared to younger patients 15 . Our results further support the existing data, although it should be emphasized that this is the first report specifically designed in AIH patients ≥70 y who were treated with prednisolone and MMF as front‐line therapy.…”

“…Another relevant question is the issue of treatment, with controversy regarding benefits in this group of patients 10,11,15,29,31 . Treating aged with high doses or lengthy intervals of immunosuppression remains a matter of concern for many physicians which is not sufficiently addressed so far, as patients aged ≥70 y are often excluded from trials 15,29 . From a clinical point of view, most hepatologists, internists and general practitioners will be reluctant to administer corticosteroids to older patients, especially when comorbidities such as osteopenia or diabetes and polypharmacy may be present.…”

“…Since 1990s, it was documented that the disease has a bimodal distribution with one peak during childhood and adolescence and another between the fourth and sixth decade 3‐5 . Today, it is well known that irrespective of ethnicity, AIH can affect both sexes and all ages with increasing prevalence in the aged 10‐16 . Although the first reports of AIH diagnosed in patients ≥60‐65 y, date more than two decades, relevant literature includes limited number of studies with a small series of patients, thus perpetuating the obscurity around AIH in this specific group of patients.…”

KASL clinical practice guidelines for management of autoimmune hepatitis 2022

“…However, AIH diagnosed in the elderly is characterized by more asymptomatic cases, more often delayed diagnosis, and higher rates of comorbidity, cirrhosis, and extrahepatic diseases, such as thyroid or rheumatic disease [ 60 , 314 - 316 ]. Elderly patients respond well to the immunosuppressive therapy, with less relapse after treatment withdrawal [ 317 , 318 ]. However, the cut-off age to define the elderly population varies from 60 to 70 years in each study, and some studies have reported no difference in clinical features and treatment responses according to age [ 315 , 319 ].…”

“…60,[314][315][316] Elderly patients respond well to the immunosuppressive therapy, with less relapse after treatment withdrawal. 317,318 However, the cut-off age to define the elderly population varies from 60 to 70 years in each study, and some studies have reported no difference in clinical features and treatment responses according to age. 315,319 In elderly patients, drug use to control other comorbidities is common.…”