A patient with autoimmune hepatitis (AIH) achieves remission on prednisolone and azathioprine. After 3 years, liver biopsy is repeated showing no inflammatory activity and normal liver enzymes for 2 years. What is the recommended next step regarding immunosuppression?
- A Cautious withdrawal of immunosuppression is possible but relapse occurs in >50%; monitor closely ✓
- B Immunosuppression should be lifelong in all AIH patients
- C Azathioprine can be stopped but prednisolone must continue indefinitely
- D Switch to mycophenolate mofetil as maintenance and then withdraw prednisolone only
Correct answer: A. Cautious withdrawal of immunosuppression is possible but relapse occurs in >50%; monitor closely
Explanation
In AIH patients with complete biochemical and histological remission for at least 2 years on treatment, cautious withdrawal of immunosuppression can be attempted; however, relapse rates are >50% within 3 years of withdrawal. Patients who do attempt withdrawal require close monitoring (liver enzymes every 3 months for 1–2 years). Lifelong treatment is often necessary in practice. Withdrawal is most successful in those with IgG normalisation and histological resolution. The relapse risk is highest in the first 12 months after discontinuation.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.