From the Guidelines
Predictors of relapse in autoimmune hepatitis after azathioprine discontinuation include shorter duration of treatment, incomplete histological resolution, elevated liver enzymes, presence of HLA DR3 or DR4 genotypes, and younger age at diagnosis, with approximately 50-80% of patients experiencing disease recurrence within 3 years, as reported in studies such as 1. The decision to withdraw azathioprine should be individualized, taking into account factors such as the absence of cirrhosis or decompensation, good tolerance of initial prednisolone treatment, and a potential precipitant of the initial episode of AIH, as suggested by the British Society of Gastroenterology guidelines 1. Some key factors that increase the risk of relapse include:
- Shorter duration of treatment (less than 2-4 years of remission)
- Incomplete histological resolution
- Elevated liver enzymes at the time of withdrawal
- Presence of HLA DR3 or DR4 genotypes
- Younger age at diagnosis
- Laboratory markers such as elevated IgG levels, positive autoantibodies (particularly anti-SLA/LP), and persistent mild transaminase elevations
- Histological features indicating higher relapse risk include residual interface hepatitis, plasma cell infiltration, and incomplete resolution of inflammation on liver biopsy prior to medication withdrawal, as noted in studies such as 1 and 1. For patients with multiple risk factors, indefinite maintenance therapy may be preferable to withdrawal, with azathioprine continued indefinitely as a chronic maintenance therapy, as recommended by studies such as 1. If withdrawal is attempted, close monitoring with liver function tests every 1-3 months for at least one year is essential to detect early relapse and reinitiate treatment promptly to prevent disease progression and fibrosis development, as emphasized by the guidelines 1 and studies such as 1 and 1.
From the Research
Predictors of Relapse of Autoimmune Hepatitis After Stopping Azathioprine
- The decision to stop azathioprine in patients with autoimmune hepatitis (AIH) is complex and depends on various factors, including the duration of remission, liver function, and the presence of cirrhosis 2.
- Studies have shown that the majority of patients with AIH will relapse after stopping azathioprine, highlighting the need for long-term therapy 2, 3.
- Predictors of relapse after stopping azathioprine include:
- Duration of remission: Patients with a shorter duration of remission are more likely to relapse after stopping azathioprine 3.
- Liver function: Patients with abnormal liver function tests are more likely to relapse after stopping azathioprine 3.
- Presence of cirrhosis: Patients with cirrhosis are more likely to relapse after stopping azathioprine 4.
- Alternative treatment options, such as mycophenolate mofetil (MMF), have been shown to be effective in maintaining remission in patients with AIH, and may be considered for patients who are intolerant to azathioprine or have a history of relapse 3, 5.
- The choice of treatment should be individualized based on the patient's specific needs and circumstances, and should take into account factors such as the risk of relapse, the presence of cirrhosis, and the patient's overall health status 6.