Hepatitis – Grade 4

Management escalation pathway

  • Suspend ICPI
  • If bilirubin < 3ULN: oral prednisolone 1 mg/kg
  • If bilirubin > 3ULN or one of the following hypoglycaemia, increasing bilirubin, lowering INR or albumin: admit patient treat intravenously: i.v. (methyl)prednisolone 2 mg/kg

Assessment and Investigations

  • Daily LFTs/INR/albumin
  • Perform US with Doppler with liver biopsy if no bleeding diasthesis (should be discussed with specialised anatomopathologist)
  • If refractory after 3 days to corticoids or bleeding diasthesis: consult hepatologist

Worsening despite steroids:

– If on oral change to i.v. (methyl)prednisolone

– If on i.v. add MMF 500-1000 mg b.d. after discussion with hepatologist

Steroid wean and ICPI rechallenge

Steroid wean:

-G2: once G1, wean over 2 weeks; re-escalate if worsening; treatment may be resumed once prednisolone < 10 mg

-G3/4: once improved to G2, can change to oral prednisolone and wean over 4 weeks

-Only resume ICPI if steroids are fully tapered; ideally this is discussed at a multidisciplinary meeting



ICPi: Immune Checkpoint Blockade Inhibition
ALT: Alanine Transaminase
AST: Aspartate Transaminase
ANA: Anti Nuclear Antibodies
ULN: Upper Limit of Normal
LFT: Liver Function Test
SMA: Smooth Muscle Antibody
LKM: Liver/Kidney Microsome type 1
SLA: Soluble Liver Antigen
LP: Liver/Pancreas
US: Ultra Sound