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