A 35-year-old woman presents with elevated transaminases, elevated serum IgG (2800 mg/dL), positive ANA (1:320) and anti-smooth muscle antibody (ASMA), and liver biopsy showing interface hepatitis with plasma cell infiltration and rosette formation. She is diagnosed with autoimmune hepatitis (AIH). Her simplified AIH score (Hennes criteria) is 8, indicating definite AIH. First-line treatment includes:
- A Prednisolone alone 40–60 mg/day for 4 weeks then taper
- B Mycophenolate mofetil alone
- C Prednisolone 30 mg/day tapered over 4 weeks, plus azathioprine 1–2 mg/kg/day for maintenance ✓
- D Ursodeoxycholic acid 15 mg/kg/day
Correct answer: C. Prednisolone 30 mg/day tapered over 4 weeks, plus azathioprine 1–2 mg/kg/day for maintenance
Explanation
Standard induction for AIH is prednisolone 30–40 mg/day (or 60 mg/day in severe disease with bridging necrosis) tapered over 4–8 weeks combined with azathioprine 50–100 mg/day (titrated to 1–2 mg/kg/day) which is the EASL-recommended combination regimen, achieving remission in >80% of patients. Azathioprine is the cornerstone of maintenance. Budesonide 9 mg/day can replace prednisolone in non-cirrhotic mild-moderate AIH to reduce systemic side effects. Mycophenolate mofetil is second-line for azathioprine-intolerant patients. UDCA is primary therapy for PBC, not AIH.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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