A 48-year-old woman with autoimmune hepatitis (anti-smooth muscle antibody positive, IgG 2800 mg/dL) achieves biochemical remission on azathioprine and prednisolone. Her liver biopsy at 2 years shows no histological activity. Prednisolone is tapered off. What is the standard recommendation regarding azathioprine?
- A Azathioprine should also be stopped simultaneously
- B Continue azathioprine indefinitely as maintenance; relapse rate is ~70-80% if stopped ✓
- C Switch azathioprine to mycophenolate mofetil for long-term maintenance
- D Stop azathioprine after 6 months of steroid-free remission
Explanation
Autoimmune hepatitis (AIH) has a relapse rate of 70-80% when immunosuppression is fully withdrawn, even after histological remission. EASL 2015 and AASLD guidelines recommend indefinite maintenance therapy with azathioprine (1-2 mg/kg/day) after prednisolone withdrawal. Withdrawal of azathioprine is only attempted after at least 2 years of complete biochemical and histological remission, and even then carries high relapse risk. Mycophenolate is used for azathioprine-intolerant patients but is not superior as first-line maintenance. Simultaneous withdrawal of both drugs leads to near-universal relapse.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.