A 30-year-old woman presents with abnormal liver enzymes (AST 280, ALT 340 U/L), serum immunoglobulin G 28 g/L, positive anti-smooth muscle antibody titre 1:160, and no history of hepatotoxin exposure. Liver biopsy shows interface hepatitis with plasma cell infiltration. What is the first-line treatment?

• A Mycophenolate mofetil monotherapy
• B Ursodeoxycholic acid
• C Prednisolone + azathioprine ✓
• D Budesonide + azathioprine in all patients

Explanation

Autoimmune hepatitis (AIH) is treated with prednisolone (or prednisone) 40–60 mg/day in combination with azathioprine 50–100 mg/day as standard induction per EASL/AASLD guidelines. This achieves remission in over 80% of patients. Budesonide (plus azathioprine) can be used in non-cirrhotic AIH without acute severe disease, as it has less systemic side-effects, but is not universally preferred over standard prednisolone. MMF monotherapy is a second-line option when azathioprine is not tolerated. UDCA is used for primary biliary cholangitis, not AIH.

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

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Written and medically reviewed by the StethoPrep medical team.