What is the most appropriate management for a 56-year-old female with autoimmune hepatitis (AIH), presenting with jaundice, lethargy, polyarthralgia, and abnormal liver function tests (LFTs), including elevated bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), and alkaline phosphatase (ALP)?

Management of Autoimmune Hepatitis in a 56-Year-Old Female

Prednisolone is the most appropriate initial management for this patient with autoimmune hepatitis presenting with jaundice, elevated liver enzymes, and positive anti-soluble liver antigen.

Diagnosis Confirmation

This 56-year-old female presents with classic features of autoimmune hepatitis (AIH):

• 2-month history of jaundice, lethargy, polyarthralgia
• Physical examination findings: jaundice, clubbing, spider naevi, hepatomegaly
• Elevated liver enzymes: bilirubin 46 IU/L, AST 200, ALT 175, ALP 104
• Positive anti-soluble liver antigen
• Negative viral serology

These findings fulfill the diagnostic criteria for AIH according to the International Autoimmune Hepatitis Group scoring system 1.

Treatment Approach

First-Line Therapy

1. Prednisolone (Option C) is the cornerstone of initial treatment for AIH:

   • Start with prednisolone 30 mg/day, reducing to 10 mg/day over 4 weeks 1, 2
   • Higher initial doses (up to 1 mg/kg/day) may be used in severe cases for more rapid normalization of transaminases 1
   • Add azathioprine 1 mg/kg/day as a steroid-sparing agent, typically initiated 2 weeks after starting prednisolone when bilirubin levels decrease 1, 2

2. Monitoring during initial treatment:

   • Weekly liver tests, blood counts for first 4 weeks
   • Then 1-3 monthly monitoring once stable 1
   • Clinical improvement should be evident within 2 weeks 1

Why Other Options Are Not Appropriate

• Liver transplantation (Option A): Reserved for patients who deteriorate despite compliance with corticosteroid therapy or have decompensated disease not responding to medical management 1. This patient has no signs of decompensation (encephalopathy, ascites) and should first receive a trial of medical therapy.

• Methotrexate (Option B): Not recommended as first-line therapy for AIH in any major guidelines 1, 2.

• Cyclosporin (Option D): May be considered as a second-line agent for patients who fail standard therapy but is not appropriate as initial treatment 1.

• Antivirals (Option E): Not indicated as viral serology is negative 1.

Expected Treatment Response

• 80-90% of patients achieve laboratory remission within 6-12 months 1
• Clinical symptoms typically resolve and liver function shows marked improvement within 3-6 months 1
• Treatment should be continued until:
  1. Normalization of serum AST/ALT, bilirubin, and IgG levels
  2. Resolution of histological inflammation on follow-up biopsy 1

Treatment Endpoints and Long-term Management

• Treatment should continue for at least 24 months 1
• Consider follow-up liver biopsy after 2 years to confirm histological remission 1
• Complete biochemical and histological resolution is the goal 1
• Relapse occurs in 50-86% of patients after drug withdrawal 1

Common Pitfalls to Avoid

1. Inadequate initial therapy: Failure to use appropriate doses of prednisolone can lead to poor disease control 2

2. Premature discontinuation of treatment: Treatment should continue for at least 2 years with normal liver tests for at least 12 months 1, 2

3. Inadequate monitoring: Regular monitoring of liver tests, blood counts, and side effects is essential 1

4. Overlooking steroid side effects: Provide calcium and vitamin D supplementation; consider DEXA bone density scans 1

This patient presents with moderate to severe AIH based on clinical and laboratory parameters, making prednisolone the most appropriate initial management, with the addition of azathioprine as a steroid-sparing agent after 2 weeks if there are no contraindications.