A 30-year-old woman with type 1 autoimmune hepatitis presents with acute severe presentation (ALT 1800 U/L, INR 2.1, total bilirubin 14 mg/dL, IgG 2800 mg/dL, ANA 1:640, ASMA positive). Liver biopsy shows panlobular necrosis with bridging necrosis and rosette formation. What is the first-line treatment?

• A Prednisolone monotherapy ✓
• B Prednisolone plus azathioprine
• C Budesonide plus azathioprine
• D Mycophenolate mofetil plus tacrolimus

Explanation

In acute severe or fulminant autoimmune hepatitis, prednisolone monotherapy (or IV methylprednisolone) is preferred initially. Azathioprine has a delayed onset of action (2-3 months) and its myelosuppressive effect may mask signs of improvement or worsen cytopenias during acute illness. Once remission is achieved and the patient stabilizes, azathioprine can be added as a steroid-sparing agent for maintenance. Budesonide is contraindicated in cirrhosis due to first-pass metabolism failure and is used only in early non-cirrhotic disease.

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

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Written and medically reviewed by the StethoPrep medical team.