A 36-year-old woman is diagnosed with autoimmune hepatitis (AIH) type 1 (ANA positive, ASMA positive, IgG 2.6 × ULN, interface hepatitis on biopsy). She achieves biochemical remission on azathioprine 100 mg/day and prednisone 5 mg/day after 2 years. How long should maintenance therapy continue and when is treatment withdrawal considered?
- A Treatment withdrawal may be attempted after at least 2 years of complete biochemical remission with histological resolution of interface hepatitis (necroinflammatory activity); relapse rate is 50–80% after withdrawal ✓
- B Therapy can be safely stopped after 6 months of normal aminotransferases
- C Indefinite therapy is required in all AIH patients regardless of histological status
- D Immunosuppression can be stopped once serum IgG normalises and the patient is clinically asymptomatic
Correct answer: A. Treatment withdrawal may be attempted after at least 2 years of complete biochemical remission with histological resolution of interface hepatitis (necroinflammatory activity); relapse rate is 50–80% after withdrawal
Explanation
EASL 2015 AIH guidelines state that treatment withdrawal can be attempted after a minimum of 2 years of complete biochemical remission (normal ALT, AST, IgG) combined with histological resolution of interface hepatitis on liver biopsy. Despite these criteria, 50–80% of patients relapse after withdrawal, particularly those who are cirrhotic, ANA/ASMA positive at high titre, or with prolonged disease course. Many patients therefore require lifelong therapy. Stopping based solely on IgG or symptoms without histological assessment is insufficient.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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