Obesity, autoimmune hepatitis

Thanks Michael for a great case! This is a case of a young person with morbid obesity who presented with abdominal pain and transaminitis ultimately found to have type 2 autoimmune hepatitis.

Main points:

  1. ) Transaminitis in the hundreds generally prompts the following differential: medication-induced/ EtOH, nonalcoholic steatohepatitis, viral hepatitis, and less commonly: autoimmune hepatitis, primary biliary cirrhosis, Wilson, alpha-1-anti-trypsin and hemochromatosis.
  2. ) Diagnosis of autoimmune hepatitis requires characteristic clinical features, and exclusion of other chronic liver conditions. Here are the ACG guidelines for evaluation of LFT abnormalities, which has some excellent algorithms regarding how to think about these labs
  3. ) Induction treatment for autoimmune hepatitis consists of prednisone +/- azathioprine. We still base our treatments from a 1975 paper

Want to learn more?

Obesity pharmacotherapy

    • Obesity should be approached with aggressive lifestyle modification including diet and exercise as well as behavioral therapy
    • Approved pharmacologic treatments for obesity (BMI >30 or 27 with comorbidities) for long term use to be used in combination with diet and exercise include: orlistat, phentermine-topiramate, locaserin, naltrexone-buproprion and liraglutide
      • Up to Date has a great chart with more detail about each of these drugs
      • Olistat decreases absorption and has a side effect of diarrhea and oily stools, some patients can get nephropathy and AKI
      • Phentermine-topiramate is a combination sympathomimetic and antiepileptic; it is contraindicated in patients taking MAOIs and pregnancy
      • Liraglutide is a GLP1 mimetic and is also used for patients with diabetes; it has GI side effects and increases the risk of pancreatitis
    • Bariatric surgery should be considered in patients with BMI > 40 or 35 with comorbid conditions

EBM: Look AHEAD trial

    • There are no positive randomized trials for mortality reduction with weight loss
    • The largest trial to date is the Look AHEAD trial in NEJM which randomized over 5000 motivated adults with diabetes and obesity to intensive lifestyle (diet + exercise) or diabetes education. The trial had to be stopped at a median follow up of 9.6 years; it showed no difference in its primary outcome of composite CV, MI, stroke and hospitalization for angina. Some criticisms of the trial include not enough follow up time, not enough power, not enough weight loss, and possibly the intervention was too late. However, regardless of these, this is still a surprising result as no doubt most people prior to this trial would suspect a dramatic CV benefit with these interventions in this patient population.
    • We will probably not see such a large /long RCT of weight loss any time in the near future. Take homes include (1) focus on obesity and diabetes prevention and (2) for patients who are obese, we have to rely on all the observational data that point to weight loss and exercise being beneficial to these patients and (3) continued research on better therapies for obesity