Table 2. Special considerations in the management of AIH in COVID-19 hotspots: A suggested approach.
| COVID-19 status | AIH status | Special considerations |
|---|---|---|
| COVID-19-negative | Diagnosis of AIH | Diagnostic algorithm same as otherwise. Liver biopsy to be planned in COVID–minimal pathway |
| Newly diagnosed patients with activity | Steroids and azathioprine can be given as indicated otherwise. Budesonide to be preferred over prednisolone in appropriate situations, in noncirrhotic patients, and in patients without acute severe AIH | |
| Patients in remission | Continue immunosuppressant at lowest recommended dose required to maintain remission. Decision to stop immunosuppression to be made in patients who have had long-term remission, as per latest guidelines for AIH. Telemedicine-based follow-up in appropriate cases | |
| Patients who require start of second-line agent | CNIs (tacrolimus) may be preferred over mycophenolate in patients with no other contraindicationsa | |
| Patients who require start of third-line agent | Infliximab may be preferred over rituximab in patients with no other contraindicationsa | |
| Decompensated cirrhosis | Treatment algorithm same as otherwise. Living donor liver transplant to be considered for urgent/emergency indications only | |
| Acute severe AIH | Diagnostic and treatment algorithm same as otherwise | |
| ALF due to AIH | Diagnostic and treatment algorithm same as otherwise. May require urgent liver transplantation | |
| COVID-19-positive | Diagnosis of AIH | Evaluation by serology, imaging same as otherwise. Decisions regarding liver biopsy to be taken on case-by-case basis |
| Newly diagnosed patients with activity/patients in remission/patients who require start of second-line agents/patients who require start of third-line agents/patients with decompensated cirrhosis | Decisions regarding management to be taken on an individualized, case-by-case basis. Patients with AIH in remission may continue immunosuppressants as before, unless other contraindications or considerations are present. Treatment decisions in patients requiring induction or escalation of therapy for AIH needs to be taken on a multidisciplinary, case-by-case basis | |
| Acute severe AIH | Need for aggressive immunosuppression likely to override all other considerations, final decision to be taken on a multidisciplinary, case-by-case basis | |
| ALF due to AIH | Decision to be taken on a multidisciplinary, case-by-case basis |
aWeak suggestion, based on data extrapolated from other conditions.