An open-label randomised-controlled trial of azathioprine vs. mycophenolate mofetil for the induction of remission in treatment-naive autoimmune hepatitis

Snijders, R.J.A.L.M.; Stoelinga, A.E.C.; Gevers, T.J.G.; Pape, S.; Biewenga, M.; Tushuizen, M.E.; ... ; Dutch Autoimmune Hepatitis (2024)

Article / Letter to editor

Background & Aims: Patients with autoimmune hepatitis (AIH) almost invariably require lifelong immunosuppressive treatment. There is genuine concern about the efficacy and tolerability of the current standard combination therapy of prednisolone and azathioprine. Mycophenolate mofetil (MMF) has emerged as an alternative option. The aim of this study was to compare MMF to azathioprine as induction therapy for AIH. Methods: In this 24-week, prospective, randomised, open-label, multicentre superiority trial, 70 patients with treatment-naive AIH received either MMF or azathioprine, both in combination with prednisolone. The primary endpoint was biochemical remission defined as normalisation of serum levels of alanine aminotransferase and IgG after 24 weeks of treatment. Secondary endpoints included safety and tolerability. Results: Seventy patients (mean 57.9 years [SD 14.0]; 72.9% female) were randomly assigned to the MMF plus prednisolone (n = 39) or azathioprine plus prednisolone (n = 31) group. The primary endpoint was met in 56.4% and 29.0% of patients assigned to the MMF group and the azathioprine group, respectively (difference, 27.4 percentage points; 95% CI 4.0 to 46.7; p = 0.022). The MMF group exhibited higher complete biochemical response rates at 6 months (72.2% vs. 32.3%; p = 0.004). No serious adverse events occurred in patients who received MMF (0%) but serious adverse events were reported in four patients who received azathioprine (12.9%) (p = 0.034). Two patients in the MMF group (5.1%) and eight patients in the azathioprine group (25.8%) discontinued treatment owing to adverse events or serious adverse events (p = 0.018). Conclusions: In patients with treatment-naive AIH, MMF with prednisolone led to a significantly higher rate of biochemical remission at 24 weeks compared to azathioprine combined with prednisolone. Azathioprine use was associated with more (serious) adverse events leading to cessation of treatment, suggesting superior tolerability of MMF

• autoimmune hepatitis
• azathioprine
• mycophenolate mofetil
• first-line treatment
• induction therapy
• randomised-controlled trial
• remission
• biochemical remission
• phase IV trial

• All authors: Snijders, R.J.A.L.M.; Stoelinga, A.E.C.; Gevers, T.J.G.; Pape, S.; Biewenga, M.; Tushuizen, M.E.; Verdonk, R.C.; Jonge, H.J.M. de; Vrolijk, J.M.; Bakker, S.F.; Vanwolleghem, T.; Boer, Y.S. de; Pronk, M.A.M.C.B.; Beuers, U.; Meer, A.J. van der; Gerven, N.M.F. van; Sijtsma, M.G.M.; Eijck, B.C. van; Ijzendoorn, M.C. van; Herwaarden, M. van; Brand, F.F. van den; Korkmaz, K.S.; Berg, A.P. van den; Guichelaar, M.M.J.; Levens, A.D.; Hoek, B.V. van; Drenth, J.P.H.; Dutch Autoimmune Hepatitis
• Date: 2024-04-30
• Journal: Journal of Hepatology
• Volume: 80
• Issue: 4
• Pages: 576 - 585
• DOI: doi:10.1016/j.jhep.2023.11.032