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Autoimmune Hepatitis: Current and Emerging Treatment Options
Prof. Christoph Schramm, Senior physician, Medical Specialist in Internal Medicine and Gastroenterology, Center for Internal Medicine I, Medical University Clinic Hamburg Eppendorf, Hamburg, Germany
Thursday, Sept. 5, 2019 · 6:06 p.m. · 43m 21s
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for this kind invitations my first time to the interest in those because ah uh looking for what
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so having a look around here in this beautiful fifty so my topic assault unit but titus
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um it's one of our favourite uh topics in hamburg since we have a
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large all patients uh this will do you mean the the diseases as well
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and we're focusing right now research also on what you mean
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appetite as what human liver diseases and immune regulation in the lever
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so whenever you have questions uh feel free to interrupt me at any time
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and uh these on mine disclosures and i would like to start with a few bullet
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points why do i think that what you mean appetite is important for all of us
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i think you all know that it's with differential diagnosis of might be elevated liver enzymes
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sometimes sometimes times up to form and liver failure
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and that around thirty percent of the patients already present with should roses
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uh which makes the i. h. unimportant differential um for
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unclear three projects can be a semiautomatic most often is symptomatic
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and uh i think it should be considered in any age group and i will come back to that a bit later
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so all the incidence is rising we have good data from denmark we have similar data from germany
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we have a point prevalence around twenty per hundred thousand
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a few years ago it's exactly the same number as we have in germany right now
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why that is we don't really know what it's it holds true for many old human diseases
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and uh on the right hand side you can see the age distribution of k. i. h. it
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often as a disease of the young females but you see that it most often
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is a disease of the elderly woman so
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i think we may have overlooked in the
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past one or the other seventy seventy five year old patient uh with what unit but titus
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so i'd like to start with the emerging in future therapies the
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future i think it's antigen specific tolerance induction that's the holy grail
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um however i think that is still far away since we
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don't have a clue what we ought to antigen is we
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don't even have a clue what he antigens on if it's
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not all tall so all i think that's for the far future
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but we're working on that on the experimental side
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so the close of future i think is understanding the
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net works that go run a yeah h. profit genesis and whenever we show such a network it means
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we don't really have a clue right i mean we put all the says inside the kinds we know wanna picture and link them
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um how i think we are starting to get some ideas
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on the sentence title kinds involved in a yeah ha patrick inflammation
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and i would like to point your interest to the th one
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t. cells and especially to the side to crime t. n. f.
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y. t. n. f. p. costs and this is unpublished work from t. now i love from our group
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when you isolate the liver infiltrating lymphocytes from
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liver biopsies obtain from yeah h. patients at diagnosis
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and compare the site so kind expression of these little infiltrating lymphocytes
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to controls you can see there's hardly any as seventeen eighty expression
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there's some lines of young got my expression a sticky th one side or kind
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but you have significantly increased t. n. f. expression in
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the c. d. for positive t. says isolated from the other
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and similar results we could recently identify four and not the ah
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said time in the liver where in humans we don't really know what
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they do that's the n. k. t. type to sell its every asset fraction
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and he um muscles it would or could show that also these says
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express high amounts of t. and f. in here h. s. compared to controls
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so the bottom line is this something with t. n. f. and why do i mention that
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because blocking t. n. f. actually is a very
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effective rescue treatment for patients with a uh h.
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this may sound a bit surprising because we know that id patience sometimes develop immune
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mediated hepatitis on the blocking of t. and have but it's not wanting an hepatitis
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if you take it away it stops that's easily treatable with with steroids
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here included a few patients with really difficult to treat
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disease many of the most of them actually serve optics
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who had prior emails oppressive treatment regimens at least two
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of them and you can see that they responded nicely
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and that prompted us to um perform a proof of
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concept study which we are currently performing in hand work
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where we try to replace the stay avoids in the initial treatment of forty minute but
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titus i think this is of utmost importance for patients for patient safety for quality of life
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and i can tell you know so far it works so this may
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be the not too far future for for the induction of remission inopportune appetites
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and i think michael will later talk more about the cup liver axis i just want to
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highlight of few findings we recently obtained
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also unpublished from the got michael but your
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time what you mean hepatitis we sampled a notch quart of patients at the controls
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control patients with p. d. c. and assertive collide to us and we
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observed that specific bacterial species the
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feudal bacteria were reduced unfortunate but titus
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and they were specially apps and in those patients who did not reach biochemical remission
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so all we're looking deeper into that at the moment and we think that
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this may also be a target for future modulation therapies
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definitely i think will not be the only treatment option
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okay let's step back to what we have today i think there are a
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lot of unmet needs in the treatment of a uh h. even today so all
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when should we diagnose it when should we consider the diagonals as
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i think i mentioned in the beginning in any form of chronic fluctuating
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elevation of chance i mean eases in any
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patients with unclear hepatitis cute carrick appetite as
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if your overall tomorrow hepatitis then the next
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step in diagnosing it is determining or to antibodies
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most centres in europe i think to work with in direct immune of fluorescence testing
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you can do with with eliza somewhat on him you know lots but they
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are knoll really comparative trials to tell which is the best method to use
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i. g. g. is frequently selectively elevated in h. i think it's a
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key feature of a yeah h. going around eighty percent of our patients
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if you have the altar antibodies and i. d. g. it is very
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likely that you have a uh h. but you still need the biopsy
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you can discuss that maybe we can discuss that later if you really need it but it's the only way to
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obtain information about being inflammatory activity and the exact stage
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of the disease and also to rule out concomitant other diseases
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if you have negative also antibodies repeated you think about
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the diagnosis in b. and you also performance of a biopsy
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if you are not show about the diagnosis you can use a simplified
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school which was developed a few years ago by our group bans couples that
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and you can see this call on the contains four variables yalta antibodies
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but you have to use i have to in order to score
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correctly we don't have points for eliza cut offs at the moment
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you determine the quantitative i. g. g. levels organic law billions and you need little
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histology and astrology is not easy point in the school because you really need a pathologist
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that would give you the information this is a typical a. i. h. was it is compatible
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and if the pathologist has not experienced in seeing these patients you will never get
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a diagnosis of it typically i. h. so you can basically forget these to see um
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i mention that because i think it's very important in hamburg and probably do the same we regularly enough
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on a weekly basis it together without pathologist and discuss the cases i think this is of utmost importance
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okay these are the authentic got is none of them is a liver specific
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um you see them in between um five and sixty percent you can differentiate
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type one from type two type tool more aggressive more kids and use
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type one why that's then you have as a positive patience sometimes referred to as type three
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doesn't really matter because the course of this type is similar
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to type one so we start a summarise these as type one
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and we have a serious of interesting um i'll the or to antibodies i mentioned them because
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be in a out antibody sometimes um
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uh cause confusion uh with remote apologists
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because like you th can also cause joint pain and if you
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have double stranded d. n. s. n. t. i. d. n. a. antibodies
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it gets confusing we have antibodies that uh associate with the disease activity that may
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or may not be to a certain degree degree pathogenic but it's not standard testing
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we perform now the first study comparing i. f. t. with
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the license and uh this will be shown at the the meeting
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in in boston and you can see that it compares very well
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so all we will be able to be finalised like cutoffs for the simplified school
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i mentioned that astrology is very important for the diagnosis um
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this is a typical histology showing them for static infiltrate it's
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very portal hepatitis so caught interface activity and then a lot of other
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things like was acting and reproduces way you need then the
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specialist apologies about probably about all the jeep apologised for the pathologist
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so we we like to perform the liver biopsy using many lap ross copy
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and this picture shows you why because if you do an ultrasound guided biopsy and here you have a macro
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not you less euros is like this once it's typical for yeah age you have a very high sampling bias
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if you had to regenerate of not you you don't
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see any scarring tissue although you have microphone modular cirrhosis
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and this information is important because zero says in h. as in
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most other diseases is associated with the worse prognosis as has been shown by several groups
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but i started g. is insufficient in
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differentiating acutely carrick yeah h. from cute billy
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because both forms have these century lobby long neck roles
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because i will have all lack all to antibodies frequently in the i. h. i. g.
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g. tends to be low often absent at the time of back notices and the correct diagnosis
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um most often can only be i'm done after spiro it with drawl
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so what we did was we give steroids and use remission withdraw the steroids
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look for the relapse if it relapses it's yeah age doesn't relapse it's most likely billy but you can never be sure
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okay if you have the diagonals of a h. then the next not so easy question is whether to
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treat or not it's not an easy question in
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advance or what takes wall in the low activity patients
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so in the guidelines is defined as lower
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than for eighteen modified hepatitis activity index points
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if you don't treat the patient which i think is fine to
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discuss with the patient then you have two more need to i'm lifelong
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because the disease tends to fluctuation activity and then i would definitely
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survey using non invasive fibrosis marcus so that we don't miss
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fibrosis progression in spite of very low trends i mean nice levels
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any activity above three should lead to treatment
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full imminent a age very difficult cases contact with the transplants and so i think that's it
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so i i h. was the disease um with the first controlled
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um try and showing lifesaving treatment with steroids
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small numbers but stairwell it's us the the mainstay of
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the induction a half of remission in h. even to date
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the guidelines say we shouldn't use remission what's the rights and we should maintain
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the mission using is a five train i think the european guideline is very reluctant
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regarding what are some night but german uh all string guideline is a bit
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more progressive i would say i think put this night is not a bad drug
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for especially younger patients all the patients with diet
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beaches and a suspicion of side effects of conventional steroids
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it's not quite as effective it's our feeling uh compared to conventional steroids but
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i think um it's worth a try if there's no circles that's a contra indication
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it's not hard green the doors one to one point five milligram
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standard poles but lower than for the treatment of i. b. d.
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so if you diagnose a patient to tell them all we're going to
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treat you with high dose steroids you're not very popular um so all
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he says the doctor prescribes a lot of toxic stuff including asbestos
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and lead and other things and the patients as uh it doesn't matter
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as long as it's not state role it's so i don't think it's
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that bad but avoiding high dose steroids is uh it's an important call
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not only for patients so these are the data from the wood
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doesn't i control trial that's the only control try in h. treatment
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we had for over forty years published already uh nine musical it
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shows you would that would doesn't i use effective in in using remission
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in this trial it was even better than a fixed those of cat is on a fixed also forty milligrams per is on
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and uh the criticism here was that most centres would not
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use a fixed dolls but an individual nice those according to
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um h. come abilities and body weight but uh that's the data that
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is out and uh it's not so bad if you compared with uh
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other data published on the um real
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life effectiveness effectiveness of steroids for induction information
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so i said reducing that also steroids may be an important goal especially for patients um
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and that is why i brought the very reason study which was
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performed by simon about the phone i'm a on a multi centre study
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also have contributed and it's trying to dissect whether hide
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those is really better than no those initials to avoid treatment
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and you divide it into two groups the one receiving
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less than all point five milligram per kilogram body weight
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and the other group more than all point five milligram per kilogram body weight
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and you can see that and then not school want four hundred fifty
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patients normalisation of trends i mean is that six months was very similar
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and also complete biochemical remission meaning also normalisation of i. d. g. i. g. g. levels
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was not different and he then that the propensity
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matching scroll saw the two groups there really comparable
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um but the steer white those besides the stay what tools
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and here hundreds and uh this is on the ten patients
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you see no statistical difference in the rate of normalisation
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of chance i mean is is after six months of treatment
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what does that mean it probably means many
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of us including ourselves in hamburg have used
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two hi steve oils as in the past i
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still believe some patients needed especially the very prominent patients
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but um i think many patients be country but what what was of conventions what's
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what should we tell the patient when we start treatment i think it is wise to tell them the chance that
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this is a lifelong diseases very high and the chance that it needs to be treated lifelong is also very high
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these are the dutch data showing the high relapse rate after trying to withdraw treatment
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in patients with a age and it also may rose on
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experience relapse rate is around ninety percent if you try to withdrawal
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now can you improve that could fiction off a successful treatment withdraw yes i think you can
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so all we're we investigated whether
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patients that remained incomplete biochemical emission
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for at least two units and um although therapy
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meaning most cases medium to low those is that happy
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then you have a chance of around fifty percent of remaining
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in remission without treatment i think this is not too bad
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it's not the majority of the patients clearly it's relatively
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few patients but i think should be offered all of them
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so what's the goal of treatment it's trained yours complete biochemical remission
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why that is the best so or gate for his topological remission we have
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we don't regularly perform followup biopsies anymore
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so that will be idea to secure the
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school but we take biochemical remission now is that good or is it not good
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it's in between i would say these are the data also from
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from hand work a few years old but it shows you all
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how well biochemical remission correlates with this to logical remission
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if you have a a t. n. i. g. g. mormon
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the likelihood that you have a moderate to high has
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to logical activities so six to eighteen points is quite low
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and it increases if you have one of them elevated and if both elevated
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the majority of patients have an activity that requires um more intense treatment
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and we have one study that shoulders that this
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differentiation between patients in his to logical be machine and
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with an m. high of more than four or more than three really met us comes from the u. k.
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and you can see that on the long term patients with moderate astrological activity
00:20:00
we'll have a worse prognosis compared to those incomplete is the logical permission
00:20:05
but this is a small single centre study think
00:20:08
it requires confirmation but it's also very difficult bit adopting
00:20:15
okay what can you do to monitor the disease you can use non invasive fibrosis measurements
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five hours can is the best validated i don't know whether you have it you know probably do
00:20:27
and we could show that if you reach biochemical remission in yeah h.
00:20:32
but over that period of the next few years
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let us stiffness significantly declines in those patients
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where you don't achieve biochemical emission levels difference increases and interestingly
00:20:49
patients with services at diagnosis after steepest decline and stiffness
00:20:54
and the treatment and this is not reduction of information so
00:20:57
these are patients that up more than six months uh treated
00:21:03
this is important because in the first months after treatment initiation
00:21:08
the best deafness to a large degree correlates with inflammatory activity as you can see here
00:21:14
these are the patients with the same colours the stephens goes
00:21:17
down here t. values going on this is induction of remission
00:21:22
but the other study was looking at the long term development of a process and
00:21:27
if you look at patients bill which are treated what treated longer than six months
00:21:34
piper scan is excellent for the production of advanced fibrosis
00:21:40
okay so all the goal is induction of remission maintenance of emission do we actually that in real life
00:21:48
no we don't
00:21:50
the states are maybe you do and down in the u. k. we don't
00:21:55
at least forty percent of patients not in remission and i can tell you
00:22:00
now it's and so it's not much different than in germany it's not much different
00:22:06
so we have to be better because not being in remission i showed your diverse deafness
00:22:12
not being in remission decreases survival i think this is an extreme example from um
00:22:19
then that pleases group but clearly i think remission is the goal
00:22:26
so what do we do if we don't achieve it
00:22:30
we have basically two groups of patients weren't role is the easy one
00:22:37
it's about ten percent of the patients we don't tolerate the initial treatment
00:22:41
so i think here we have a relatively clear definition and we have um
00:22:48
good jokes better then in using the mission underwear tolerated
00:22:53
the other patients with insufficient response to standard treatment um much more difficult
00:22:59
here we have a huge unmet need um we don't have
00:23:02
a validated to finish what is insufficient response on the long term
00:23:07
um we have very heterogeneous paper and patient populations if you look at
00:23:12
the case devious the studies you cannot really compare these regarding preach treatment
00:23:17
um and we have a huge reporting bias because we only have
00:23:22
positive case serious and all the rest will not be published so
00:23:26
it's very difficult um and to tell what tool i recommend here so in patients with intolerance
00:23:34
i think we could determinism and have a light levels i think the greater value of
00:23:40
doing this is in controlling adherents of a younger patients transition phase patients we regularly that
00:23:47
you can think of continuing stay what mortal therapy but then also this is not very well tolerated
00:23:53
'em on the long term with this the night maybe an option that very little data on that
00:23:59
um and then the two main jocks for the maintenance of permission i think
00:24:05
it's in the cup to pure and and michael fan late i think both
00:24:09
ah but tolerated even m. p. in patients
00:24:13
with a is that intolerance in seventy percent
00:24:16
would be tolerated similar to the experience for my b. d. treatment it's much cheaper it's not
00:24:23
i would say it's not zero to janet but in brackets um so
00:24:27
we don't have evidence that it's total janet in in uh in humans
00:24:34
and and then have side eater agenda which often precludes it's using a few minutes
00:24:40
these are some data and then have in is that
00:24:44
intolerant patients twenty five half answer emission half um no remission
00:24:52
and this is concerned and some other studies now
00:24:56
intolerant patients high rate of permission using m. m. f. patients but non response
00:25:03
probability of achieving complete biochemical remission in these patients as much
00:25:08
lower let's not the drug of choice in patients with insufficient response
00:25:14
so these are the data for the cup to pure and you can
00:25:17
see only six of twenty eight patients did not tolerate and p. when they
00:25:23
when taller and uh to as a time green and again i'm a high rate of complete or partial remission
00:25:33
now what should we think off in be insufficient responders
00:25:39
maybe we missed diagonals the disease what part of
00:25:43
the disease maybe there's a concomitant nash we will
00:25:47
um deteriorate with intensifying treatment so i think
00:25:51
the uh the biopsy has a great value
00:25:55
we should always question adherence i think it's a largely neglected area in the treatment of a.
00:26:00
i. h. i. think okay just one of the diseases in that but other g. would probably
00:26:06
the highest rate of non adherence because
00:26:10
we use quite an unpleasant and toxic drugs
00:26:15
increase his idols up to two two point five milligrams per kilogram
00:26:20
we then also like to determine examined to have a lights um because we
00:26:24
sometimes then combine out of four in all the phase of i mean it's so
00:26:30
it's a bit experiment thought but it works if you have a compliant patient you
00:26:36
can do it but you have to frequently controlled especially in the beginning the blood counts
00:26:42
it's always individualised and um i think basically you can try any jerk you
00:26:50
have experience with especially from the transplant field a very few drugs i would not
00:26:56
i would say they're definitely not work
00:27:00
so i'll show you some of the data published
00:27:03
mostly case reports case serious than not control trial data
00:27:07
uh concerning second that line treatment here using the addition
00:27:11
after crawling most published from the birmingham cool it works
00:27:17
using ever only most it works only five patients
00:27:22
but anyway it eating told me some of them have remained in recognition for many years
00:27:29
targeting be sounds which looks him up it also
00:27:33
works nodding all patients i'll only experience is not
00:27:38
that positive but we've tried it in only few patients but targeting be sets clearly is of interest
00:27:44
because there's now an ongoing trial being but try uh from the barges
00:27:50
uh with the bath receptor antibody very interesting trier
00:27:55
but it has great difficulties in recruiting and that's always
00:27:59
um uh in danger of being stopped prematurely
00:28:04
so i think we should all try to support this trial we do our best
00:28:07
but we have not included a single patients off it's a very difficult right after it
00:28:14
so the conclusion regarding second and third line treatment um there's very low level
00:28:19
evidence it should always be individualised treatment and almost in brackets everything can be tried
00:28:29
so if we don't achieve complete remission or if during the
00:28:33
course of disease called a static liver enzymes rise we should
00:28:39
all was also think the possibility of variance and drums meaning
00:28:44
patients are they i. h. will develop signs of p. u. c. l. p. b. c.
00:28:49
or the other way around we initially had p. b. c. patient with very high inflammatory activity
00:28:54
which reach the age with immune suppression but the call the status remains
00:29:00
um we have a very variable degree of
00:29:03
inflammatory activity in these colour static the diseases and
00:29:08
in doubt i think we should repeat what antibody testing we should look at the large bile
00:29:13
ducts using m. r. c. p. especially in the younger patients with with the h. and um
00:29:20
in doubt even do a biopsy during follow up
00:29:25
it really isn't clinic an e. p. yawn be
00:29:28
induction of a biochemical remission and disease progression and
00:29:33
and this will be probably on the line but patients and their representatives we should
00:29:38
aim at avoiding long term side effects of treatment short term related side effects of steroids
00:29:44
osteoporosis skin cancer on the long term and we should
00:29:47
recommend a regular a check for that and in the end
00:29:52
all patients improving quality of life is of utmost importance we're doing really badly with that
00:29:58
because we don't even know what in yes the quality of life in our age patients
00:30:05
just one example we recently completed a study on um cost to process
00:30:09
and all still paying me ah it's frequency now i i. h. patients
00:30:13
and the major missed factor not surprising me poster prose as opposed to avoid use another
00:30:18
argument to spear steve or it's in in this paper you can find the risk calculator
00:30:24
um how to um identify those patients at highest
00:30:29
risk of developing osteoporosis but i think in general
00:30:33
at least we try to do that at our sense i think we should it's
00:30:36
can do a bone scan in every patient without human appetite is to start with
00:30:43
so quality of life is reduced the mental
00:30:46
component the physical component shown now in several studies
00:30:51
and um i mention that because i think we
00:30:55
and the existing made the psychological burden of this disease
00:31:00
the feel of side effects on the long term the feel of disease progression
00:31:05
um and also get that this leads to the
00:31:07
really increased rates of anxiety symptoms also of depressive symptoms
00:31:13
um and it's about four times as high as in the general population comparable to
00:31:18
other chronic rheumatic diseases and one of the
00:31:22
major risk factors dan is still white treatment
00:31:30
not the guidelines say we should try to withdraw
00:31:33
steroids within the first six to twelve months of treatment
00:31:38
we carried a very large german insurance company registry from the t. k. k.
00:31:44
uh the t. k. uh insurance company with over eight might million injured people
00:31:49
we identified the patients with a h. and then we um
00:31:52
compare that to the data we have on prescriptions and scaring the
00:31:59
in germany over fifty percent of the patients
00:32:03
that are continuously treated with partners all buttons along
00:32:08
ten percent with buttons on and another twenty five percent with this online
00:32:14
meaning in the and the vast majority of patients in real life still is treated
00:32:22
what's the what's so we really not doing well in
00:32:26
that respect and another interesting feature of this uh study was
00:32:30
the high rate of personal use um so i think what happens and in in tractors is that
00:32:37
patients not answering remission of frequently a given or so in addition
00:32:43
to uh into the biochemical remission which may not be
00:32:46
too bad we know from japan but they treat yeah age
00:32:50
only with various all um we we're not big friends of that but i don't want to say it doesn't work
00:32:58
so i'll let me summarise the unmet needs in what you know
00:33:01
but types is we should uh and void treatment related um side effects
00:33:08
avoid to steer whites first and second line working on that
00:33:13
i think we need more effective treatments to interview was and maintained remission with less side effects
00:33:20
we need treatment which improves health related quality of life and doesn't make it worse um this is
00:33:27
difficult because we don't have a disease specific tools
00:33:31
to measure quality of life we desperately need that
00:33:35
we have unmet needs because we still have patients will progress to cirrhosis in
00:33:39
spite of treatment sometimes because they stop treatment for a few months really yes
00:33:45
and um mainly in patients with zeros is insufficient
00:33:48
treatment response and lack of remission we have disease progression
00:33:53
so let me stop uh this presentation um by mentioning the european reference net work
00:33:59
for a diseases we just had a meeting in hamburg and some of you attended
00:34:04
and i think this is a unique opportunity to improve
00:34:09
the life of patients with a h. in the future
00:34:12
because it's the first initiative starting on my two
00:34:15
cents a perspective high quality the registry which will then
00:34:21
give us information on different types of second and
00:34:24
third night treatments which big and then compare and decide
00:34:28
which ones would be best for our patients if you want to contribute that
00:34:32
you're very welcome you don't have to be a member of your in reference network
00:34:37
you can be a collaborative partner and a contact our data manager or myself if you're interested
00:34:43
and with this i would like to thank the t. one be the funding agencies and or if
00:34:49
you want to come off and uh learn about a broad spectrum of
00:34:53
separate or the g. very welcome to attend or apology course in homework
00:34:58
in november it's not the best time of the year to be in hamburg but uh it's always nice and i'm
00:35:03
so thanks very much and i'm happy to answer questions or e. e.
00:35:20
uh_huh
00:35:24
yeah
00:35:34
oh
00:35:37
uh_huh
00:35:42
yeah
00:35:52
yeah
00:35:54
yeah
00:35:57
or
00:36:02
so how to differentiate really from acute picked eric yeah age it's extremely difficult
00:36:09
even flux but a pathologist uh have apology apologised for
00:36:13
the pathologists we've we've just finished a study involving for experts
00:36:21
into the pathology
00:36:23
and you cannot believe how how high the variation was so there was basically no consensus down
00:36:29
um and the one thing i can tell you an hour that may be
00:36:33
worth looking at this the number of class must cells in the liver biopsy
00:36:39
all the rest is very difficult video signal fills you see in both uh
00:36:44
the century lot below than much of the liver you seen both of them
00:36:50
probably in the end you can combine the number of persons says in the biopsy and the level of i. g. g.
00:36:56
that's our gut feeling at the moment but it's i think one
00:36:59
of the most difficult really topics if you wanna know what right away
00:37:05
but i'm sure in the future they'll be molecular signatures differentiating the tool
00:37:12
but there's no date was off on that
00:37:15
uh_huh oh sorry
00:37:22
oh hey i i
00:37:26
yes
00:37:33
so um we don't wait too long if the
00:37:36
patient has achieved by chemical remission we within the next
00:37:42
two to four weeks withdraw to stay what's completely we don't keep it in for six or twelve months
00:37:49
and many patients remain in remission so i think it's uh i
00:37:52
mean there's a big debate actually whether you really need the voids
00:37:58
q. really this is another difficult topic uh clearly
00:38:03
many patients respond people to fully however i don't know
00:38:07
any control trial comparing steroids but most airports and many
00:38:12
patients respond beautifully with us to what's going on that
00:38:19
you were
00:38:26
yeah
00:38:28
mm fruit
00:38:30
yeah
00:38:33
yeah
00:38:39
oh
00:38:41
yeah so all what uh my personal preferences for that line treatment so i am mum
00:38:48
i'm a small fan off the combination of other pouring organism
00:38:53
it works
00:38:54
i'm in selected patients and then um i
00:38:59
think the addition after calling was is an option
00:39:04
continue treating with a slow
00:39:07
and uh the third one that um we have now quite a
00:39:11
lot of experience uh with is a switch to in fixing up
00:39:17
and interestingly when you block t. n. f. you should use in fixing up and not utterly warm up
00:39:24
why we don't know but it seems to be
00:39:29
well we we guess it's the binding of the antibody to to says correctly
00:39:35
and not just a blocking soluble tina
00:39:40
but this is now speculation
00:39:45
clearly i think these patients at increased risk of infectious complications we should always be
00:39:52
very cautious and especially in elderly patients uh you
00:39:56
see a lot of viral complications stands also reacted haitians
00:40:02
um so i think it should always be weighed against the risk
00:40:06
and that that holds i think especially true for the full moon and a yeah each patient um
00:40:12
whom we treat with high dose steroids on the i. c.
00:40:15
u. was it had an enormous risk of infectious complications underneath it
00:40:21
so i think that is that is one of the most difficult treatment decisions
00:40:28
whoa something between i think fifty and a hundred milligram i. v. right and so on that's what we do
00:40:36
we tend to give for example three days hundred milligrams and if there's no
00:40:40
response after three to five days than it was in the direction of transportation
00:40:52
no
00:40:54
i mean those really critically ill
00:40:59
no
00:41:02
but maybe it's with that
00:41:04
let's wait for the date of this on the ongoing of the ongoing study
00:41:12
but uh
00:41:16
what
00:41:19
i mean
00:41:24
uh
00:41:26
yeah
00:41:27
yeah
00:41:33
no to be honest no i don't know any data and um we're not checking
00:41:39
you
00:41:41
yeah
00:41:45
yeah
00:41:48
ooh
00:41:56
two good point
00:42:01
e. p. h. d.s
00:42:06
yeah yeah
00:42:09
yeah yeah
00:42:12
yeah
00:42:14
yeah
00:42:16
yeah i i would miss so kansas abeyance and uh vaccinations i think it's a very
00:42:24
important topic we uh recommend to every patient on the immune suppression the yearly skin check
00:42:29
um although the insurance companies in germany only paid every two years um mm
00:42:35
we recommend the vaccinations flew you mccorkle
00:42:40
vaccines arm and now also onto ourselves also
00:42:46
who i think that's very important especially for the elderly patients with intense thing it's a question
00:42:51
and um i think all the all the data suggests that the risk is not too high
00:42:57
i think uh yeah h. server takes should also be a survey for
00:43:01
h. c. c. if not every six months i think every twelve months
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Prof. Michael Trauner, Chair of Gastroenterology and Hepatology, Department of Medicine III, Medical University Clinic, Vienna, Austria
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