A 38-year-old woman with autoimmune hepatitis on prednisolone and azathioprine has been in biochemical remission for 2 years (ALT 18 IU/L, normal IgG). A liver biopsy is performed before considering drug withdrawal. It shows minimal lobular activity (HAI score 3/18) with complete fibrosis regression (Metavir F1). What does current guidance recommend regarding immunosuppression withdrawal?
- A Attempt slow drug withdrawal with close biochemical monitoring only if HAI ≤3 and fibrosis ≤F1 ✓
- B Stop all treatment immediately since fibrosis is regressed
- C Continue immunosuppression indefinitely regardless of biopsy
- D Switch to mycophenolate mofetil and attempt withdrawal in 6 months
Explanation
EASL guidelines for autoimmune hepatitis recommend that drug withdrawal may be attempted after ≥2 years of complete biochemical remission AND liver biopsy confirming minimal inflammatory activity (HAI ≤3/18) with no or minimal fibrosis (≤F1 Metavir). This patient meets both criteria. However, withdrawal must be gradual (prednisolone taper over months) with monthly liver function monitoring for 12 months, as relapse occurs in ~50–90% of patients. Indefinite immunosuppression is justified for cirrhosis (F4) or failure to achieve biopsy remission. Abrupt cessation risks severe relapse.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.