A 45-year-old man with autoimmune hepatitis (AIH) achieves biochemical remission on azathioprine 100 mg/day + prednisolone 5 mg/day. After 3 years of remission, a liver biopsy shows histological remission (minimal inflammatory activity, no fibrosis). He asks about stopping therapy. What is the correct counselling?

• A Therapy should never be discontinued in AIH
• B Stopping azathioprine alone is sufficient if prednisolone is continued
• C Therapy should be stopped immediately after 2 years of remission
• D Therapy can be withdrawn with high risk of relapse (~50–80%), requiring close follow-up ✓

Explanation

In AIH, withdrawal of immunosuppressive therapy after sustained biochemical and histological remission (typically ≥2–3 years) is associated with high relapse rates of 50–80%. EASL 2015 guidelines recommend that therapy withdrawal may be attempted only after ≥2 years of complete biochemical and histological remission, but patients must be informed of the high relapse risk and monitored closely with LFTs every 3 months for 1 year, then every 6 months. Many patients require lifelong therapy.

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

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Written and medically reviewed by the StethoPrep medical team.