A 45-year-old woman with autoimmune hepatitis on azathioprine and prednisolone develops decompensation (ascites, jaundice). Liver biopsy shows bridging fibrosis and interface hepatitis with plasma cell infiltrate. ALT is 280 U/L. The best therapeutic decision is:
- A Increase prednisolone dose to 60 mg/day
- B Switch to tacrolimus monotherapy
- C Add mycophenolate mofetil (MMF) and consider liver transplant evaluation ✓
- D Start tenofovir to cover occult hepatitis B reactivation
Explanation
In autoimmune hepatitis that fails standard azathioprine + prednisolone therapy (treatment failure or incomplete response with ongoing fibrosis/decompensation), mycophenolate mofetil (MMF) is the most evidence-based second-line agent, achieving remission in 60–80% of azathioprine-intolerant or refractory cases. Decompensation also mandates liver transplant evaluation, as patients with cirrhotic decompensation not responding to immunosuppression have a high short-term mortality. Simply increasing steroids risks opportunistic infection without addressing fibrotic progression.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.