S2789 Comparative Efficacy of Immunosuppressants in Autoimmune Hepatitis: A Network Meta-Analysis

Introduction: Autoimmune hepatitis (AIH), a rare chronic liver disease affecting 15.65/100,000 globally, causes progressive liver inflammation often leading to cirrhosis. Without treatment, 5-year mortality can reach up to 50%. However, life expectancy is 90% in 10 years with treatment, emphasizing the importance of timely and effective therapy. This network meta-analysis compares induction and maintenance regimens for remission and relapse prevention. Methods: We systematically searched PubMed, Scopus, Cochrane, ScienceDirect, Google Scholar and ClinicalTrials.gov through April 2025, including 6 RCTs and 1 retrospective study. PRISMA-guided pairwise network meta-analysis evaluated biochemical/histological remission (induction phase) and relapse-free survival (maintenance phase) using a net meta package on R. Results: A total of 718 patients with a mean age 42.12 ± 14.25 years (23.7% men) were analyzed. Chloroquine + prednisolone showed highest biochemical remission likelihood (P-score = 0.97; RR = 2.98, 95% CI: 1.06–8.40), followed by mycophenolate + prednisolone (P-score = 0.50; RR = 1.12, 95% CI: 1.00–1.25; I² = 45.8%) and azathioprine + prednisolone (P-score = 0.02 ). Among monotherapies, budesonide had the highest remission probability (P-score = 0.82; RR = 1.10, 95% CI: 0.98–1.24, P = 0.09), followed by cyclosporin A (P-score = 0.37; RR = 0.93, 95% CI: 0.47–1.83, P = 0.84) and prednisolone (P-score = 0.31). Azathioprine + prednisolone ranked best for histological remission (P-score = 0.72), followed by mycophenolate mofetil + prednisolone (P-score = 0.43; RR = 0.87 , 95% CI: 0.56-1.35, P = 0.55) and chloroquine + prednisolone (P-score = 0.36; RR = 0.80, 95% CI: 0.36-1.76, P = 0.58). Chloroquine monotherapy (P-score = 0.96; RR = 2.90, 95% CI: 1.05–8.00, P = 0.04) outperformed ursodeoxycholic acid (P-score = 0.33; RR = 1.09, 95% CI: 0.53–2.22, P = 0.82) in maintenance. Conclusion: Chloroquine + prednisolone emerges as optimal for biochemical remission and relapse prevention, while azathioprine + prednisolone excels histologically. Overall, Chloroquine demonstrates a notable efficacy in both the induction and maintenance phases of the treatment. However, the scarcity of comparative data reveals a significant knowledge gap. Large-scale randomized controlled trials directly comparing regimens and biomarker studies to guide treatment monitoring are needed to optimize AIH management.