A 45-year-old woman with autoimmune hepatitis on azathioprine 100 mg/day and prednisolone 5 mg/day has sustained remission (normal transaminases, normal IgG) for 3 years. She asks about withdrawing therapy. Liver biopsy shows minimal interface hepatitis. What is the relapse rate after azathioprine withdrawal in autoimmune hepatitis achieving biochemical and histological remission?

• A Less than 10% relapse if histological remission is achieved
• B 30–40% relapse but all respond well to re-treatment without significant liver damage
• C Relapse is extremely rare (< 5%) if treatment duration exceeds 4 years
• D Approximately 50–80% relapse within 3 years of withdrawal ✓

Explanation

Autoimmune hepatitis has a high relapse rate after immunosuppressive therapy withdrawal — approximately 50–80% of patients relapse within 3 years even when biochemical and histological remission are confirmed. This high relapse rate means that lifelong maintenance therapy is required in the majority of patients. EASL guidelines recommend treatment withdrawal only after at least 2 years of complete biochemical remission confirmed by normal transaminases, normal IgG, and histological resolution of interface hepatitis — and even then, patients must be counselled about the high relapse probability and the need for close monitoring. Relapse after withdrawal often responds to re-treatment but carries risk of cumulative liver damage.

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

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