Bittermann Therese, Yagan Lina, Kathawate Ranganath G, Weinberg Ethan M, Peyster Eliot G, Lewis James D, Levy Cynthia, Goldberg David S
Division of Gastroenterology and Hepatology Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Hepatology. 2025 Feb 1;81(2):423-435. doi: 10.1097/HEP.0000000000000961. Epub 2024 Jun 12.
While avoidance of long-term corticosteroids is a common objective in the management of autoimmune hepatitis (AIH), prolonged immunosuppression is usually required to prevent disease progression. This study investigates the patient and provider factors associated with treatment patterns in US patients with AIH.
A retrospective cohort of adults with the incident and prevalent AIH was identified from Optum's deidentified Clinformatics Data Mart Database. All patients were followed for at least 2 years, with exposures assessed during the first year and treatment patterns during the second. Patient and provider factors associated with corticosteroid-sparing monotherapy and cumulative prednisone use were identified using multivariable logistic and linear regression, respectively.The cohort was 81.2% female, 66.3% White, 11.3% Black, 11.2% Hispanic, and with a median age of 61 years. Among 2203 patients with ≥1 AIH prescription fill, 83.1% received a single regimen for >6 months of the observation year, which included 52.2% azathioprine monotherapy, 16.9% azathioprine/prednisone, and 13.3% prednisone monotherapy. Budesonide use was uncommon (2.1% combination and 1.9% monotherapy). Hispanic ethnicity (aOR: 0.56; p = 0.006), cirrhosis (aOR: 0.73; p = 0.019), osteoporosis (aOR: 0.54; p =0.001), and top quintile of provider AIH experience (aOR: 0.66; p = 0.005) were independently associated with lower use of corticosteroid-sparing monotherapy. Cumulative prednisone use was greater with diabetes (+441 mg/y; p = 0.004), osteoporosis (+749 mg/y; p < 0.001), and highly experienced providers (+556 mg/y; p < 0.001).
Long-term prednisone therapy remains common and unexpectedly higher among patients with comorbidities potentially aggravated by corticosteroids. The greater use of corticosteroid-based therapy with highly experienced providers may reflect more treatment-refractory disease.
虽然避免长期使用皮质类固醇是自身免疫性肝炎（AIH）管理中的一个常见目标，但通常需要长期免疫抑制以防止疾病进展。本研究调查了美国AIH患者中与治疗模式相关的患者和医疗服务提供者因素。
从Optum的去识别化临床信息数据集市数据库中确定了一个患有新发和现患AIH的成人回顾性队列。所有患者至少随访2年，在第一年评估暴露情况，在第二年评估治疗模式。分别使用多变量逻辑回归和线性回归确定与皮质类固醇节省单药治疗和泼尼松累积使用相关的患者和医疗服务提供者因素。该队列中女性占81.2%，白人占66.3%，黑人占11.3%，西班牙裔占11.2%，中位年龄为61岁。在2203例有≥1次AIH处方配药的患者中，83.1%在观察年接受单一治疗方案>6个月，其中包括52.2%硫唑嘌呤单药治疗、16.9%硫唑嘌呤/泼尼松治疗和13.3%泼尼松单药治疗。布地奈德的使用不常见（联合使用占2.1%，单药治疗占1.9%）。西班牙裔种族（调整后比值比：0.56；p = 0.006）、肝硬化（调整后比值比：0.73；p = 0.019）、骨质疏松症（调整后比值比：0.54；p = 0.001）以及医疗服务提供者AIH经验处于最高五分位数（调整后比值比：0.66；p = 0.005）与皮质类固醇节省单药治疗的较低使用独立相关。糖尿病患者（+441毫克/年；p = 0.004）、骨质疏松症患者（+749毫克/年；p < 0.001）以及经验丰富的医疗服务提供者（+556毫克/年；p < 0.001）的泼尼松累积使用量更大。
长期泼尼松治疗仍然常见，并且在可能因皮质类固醇而加重合并症的患者中意外地更高。经验丰富的医疗服务提供者更多地使用基于皮质类固醇的治疗可能反映了更难治疗的疾病。
