- Suspend ICPI
- Consult an expert (e.g. hepatologist) to discuss liver biopsy and initiation of systemic corticosteroid therapy with solumedrol IV
- Low threshold to admit if clinical concern (hypoglycaemia, increasing bilirubin, signs of hepatic dysfunction)
- If only ALT are elevated (without signs of liver dysfunction), a "wait and see" strategy might be discussed
- If R ratio points toward mixt or cholestatic hepatitis, treat with ursofalk

- Blood sample every 1-3 days
- Steroid wean : once G1, wean over 2 weeks
- For G3, rechallenge may be discussed after normalisation to grade 1

If worsening despite steroids:
- If on oral corticosteroids, change to IV methylprednisolone
- If on IV, consider adding mycophenolate mofetil (MMF) 500-1000 mg b.d. or tacrolimus or TNF blocker (after discussion with hepatologist)