A 35-year-old woman is diagnosed with autoimmune hepatitis (AIH). Liver biopsy shows interface hepatitis with plasma cell infiltration. ALT is 620 U/L and IgG is 28 g/L. She is started on prednisolone. After 4 weeks her ALT remains at 310 U/L. What is the standard add-on immunosuppressive therapy at this stage?

• A Mycophenolate mofetil as first alternative if azathioprine not tolerated
• B Rituximab IV as second-line therapy
• C Azathioprine 50–150 mg/day added to prednisolone ✓
• D Tacrolimus added immediately regardless of thiopurine status

Explanation

EASL 2015 and AASLD 2019 guidelines recommend that azathioprine be added to prednisolone as standard combination therapy for AIH, either at induction or within the first few weeks when steroid tapering begins. Combination therapy allows lower steroid doses and reduces side effects. Azathioprine should be checked against TPMT genotype to avoid myelotoxicity. Mycophenolate mofetil is the alternative for azathioprine-intolerant patients (not the initial add-on). Rituximab and tacrolimus are reserved for refractory AIH that fails standard therapy.

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

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