Sirolimus
Sirolimus (also known as rapamycin) inhibits the mammalian target of rapamycin, and has been studied in the treatment of autoimmune hepatitis (AIH).[50]Selvarajah V, Montano-Loza AJ, Czaja AJ. Systematic review: managing suboptimal treatment responses in autoimmune hepatitis with conventional and nonstandard drugs. Aliment Pharmacol Ther. 2012 Oct;36(8):691-707.
http://onlinelibrary.wiley.com/doi/10.1111/apt.12042/full
http://www.ncbi.nlm.nih.gov/pubmed/22973822?tool=bestpractice.com
[55]Chatrath H, Allen L, Boyer TD. Use of sirolimus in the treatment of refractory autoimmune hepatitis. Am J Med. 2014 Nov;127(11):1128-31.
http://www.ncbi.nlm.nih.gov/pubmed/24979741?tool=bestpractice.com
Further research is needed before this drug can be incorporated in the current management strategy.
Rituximab
Rituximab is a monoclonal antibody against CD20 that has been studied in the treatment of AIH.[50]Selvarajah V, Montano-Loza AJ, Czaja AJ. Systematic review: managing suboptimal treatment responses in autoimmune hepatitis with conventional and nonstandard drugs. Aliment Pharmacol Ther. 2012 Oct;36(8):691-707.
http://onlinelibrary.wiley.com/doi/10.1111/apt.12042/full
http://www.ncbi.nlm.nih.gov/pubmed/22973822?tool=bestpractice.com
[56]D'Agostino D, Costaguta A, Álvarez F. Successful treatment of refractory autoimmune hepatitis with rituximab. Pediatrics. 2013 Aug;132(2):e526-30.
http://www.ncbi.nlm.nih.gov/pubmed/23821693?tool=bestpractice.com
Further research is needed before this drug can be incorporated in the current management strategy.
Infliximab
Infliximab, a recombinant chimeric monoclonal antibody against tumour necrosis factor-alpha, has been used as a salvage therapy in refractory AIH.[57]Weiler-Normann C, Schramm C, Quaas A, et al. Infliximab as a rescue treatment in difficult-to-treat autoimmune hepatitis. J Hepatol. 2013 Mar;58(3):529-34.
http://www.ncbi.nlm.nih.gov/pubmed/23178709?tool=bestpractice.com
AIH appears to be an infrequent adverse effect of infliximab treatment.[16]Jenkins A, Austin A, Hughes K, et al. Infliximab-induced autoimmune hepatitis. BMJ Case Rep. 2021 May 24;14(5):e239944.
http://www.ncbi.nlm.nih.gov/pubmed/34031069?tool=bestpractice.com
[58]Wong F, Al Ibrahim B, Walsh J, et al. Infliximab-induced autoimmune hepatitis requiring liver transplantation. Clin Case Rep. 2019 Sep 27;7(11):2135-9.
https://onlinelibrary.wiley.com/doi/10.1002/ccr3.2456
http://www.ncbi.nlm.nih.gov/pubmed/31788265?tool=bestpractice.com
[59]Karanfilian B, Mahpour N, Sarkar A. Infliximab drug-induced autoimmune hepatitis in a patient with Crohn's ileocolitis. Am J Ther. 2020 Dec 29 [Epub ahead of print].
http://www.ncbi.nlm.nih.gov/pubmed/33416253?tool=bestpractice.com
Ursodeoxycholic acid monotherapy
A hydrophilic bile acid with immunomodulatory capabilities that alter the human leukocyte antigen class I antigen expression on cellular surfaces to suppress immunoglobulin production. Ursodeoxycholic acid has been studied as adjunctive therapy in a controlled trial of patients with type 1 AIH, and in patients with primary biliary cirrhosis with additional features of AIH.[60]Czaja AJ, Carpenter HA, Lindor KD. Ursodeoxycholic acid as adjunctive therapy for problematic type 1 autoimmune hepatitis: a randomized placebo-controlled treatment trial. Hepatology. 1999 Dec;30(6):1381-6.
http://www.ncbi.nlm.nih.gov/pubmed/10573515?tool=bestpractice.com
[61]Joshi S, Cauch-Dudek K, Wanless IR, et al. Primary biliary cirrhosis with additional features of autoimmune hepatitis: response to therapy with ursodeoxycholic acid. Hepatology. 2002 Feb;35(2):409-13.
https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1053/jhep.2002.30902
http://www.ncbi.nlm.nih.gov/pubmed/11826416?tool=bestpractice.com
US guidelines suggest that ursodeoxycholic acid may be helpful in patients with concurrent autoimmune sclerosing cholangitis.[62]Squires RH, Ng V, Romero R, et al. Evaluation of the pediatric patient for liver transplantation: 2014 practice guideline by the American Association for the Study of Liver Diseases, American Society of Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Hepatology. 2014 Jul;60(1):362-98.
http://onlinelibrary.wiley.com/doi/10.1002/hep.27191/full
http://www.ncbi.nlm.nih.gov/pubmed/24782219?tool=bestpractice.com