A 50-year-old woman has autoimmune hepatitis (AIH) with interface hepatitis on biopsy, IgG 3200 mg/dL, ANA 1:640, anti-smooth muscle antibody positive. She is started on prednisolone. At 3 months, her ALT has normalised but prednisolone dose is being tapered. Which maintenance strategy reduces steroid toxicity while maintaining remission?

• A Continue prednisolone monotherapy indefinitely at 20 mg/day
• B Mycophenolate mofetil is first-line maintenance in all AIH patients
• C Taper prednisolone to zero within 3 months once biochemical remission is achieved
• D Azathioprine 1–2 mg/kg/day as steroid-sparing agent, aiming to reduce prednisolone to ≤10 mg/day or discontinuation ✓

Explanation

Standard maintenance therapy for AIH involves azathioprine (1–2 mg/kg/day) as the steroid-sparing agent, added once initial response is established, allowing reduction of prednisolone dose to ≤10 mg/day or ideally discontinuation to minimise long-term steroid toxicity (osteoporosis, diabetes, Cushingoid features). The IAIHG recommends dual therapy for most patients. Mycophenolate mofetil (MMF) is reserved for azathioprine intolerance or incomplete response. Premature complete steroid withdrawal within 3 months carries high relapse risk (50–80% relapse on withdrawal after short-term therapy).

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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