A 55-year-old woman with autoimmune hepatitis (AIH) on prednisolone 5 mg + azathioprine 100 mg achieves biochemical remission (normal ALT, IgG). She has been in remission for 3 years. Liver biopsy is performed and shows minimal interface hepatitis (HAI 3/18). What is the next appropriate management step?
- A Maintain current therapy — 3 years is insufficient for therapy withdrawal attempt ✓
- B Discontinue all therapy — she is in remission
- C Reduce prednisolone to 2.5 mg and maintain azathioprine, repeat biopsy in 1 year
- D Switch to mycophenolate mofetil monotherapy
Explanation
EASL 2019 AIH guidelines recommend that treatment withdrawal should only be considered after at least 2–3 years of complete biochemical AND histological remission (normal liver histology or minimal residual hepatitis). Residual interface hepatitis on biopsy (HAI activity, even mild) is associated with high relapse rates (>80%) upon treatment withdrawal. Continuing current therapy is appropriate here given histological activity despite clinical remission. Relapse rates after attempted withdrawal are 50–90% overall, so withdrawal in AIH requires histological confirmation of complete remission.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.