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08.05.2017 | Autoimmune, Cholestatic, and Biliary Diseases (S Gordon and C Bowlus, Section Editors) | Ausgabe 2/2017

Current Hepatology Reports 2/2017

Autoimmune Hepatitis: When Is It Safe to Stop Therapy, or Withhold Therapy Altogether?

Zeitschrift:
Current Hepatology Reports > Ausgabe 2/2017
Autoren:
Christina Weiler-Normann, Johannes Hartl, Ansgar W. Lohse
Wichtige Hinweise
Christina Weiler-Normann and Johannes Hartl are equal contribution
This article is part of the Topical Collection on Autoimmune, Cholestatic, and Biliary Diseases

Abstract

Purpose of Review

Despite the excellent treatment response in autoimmune hepatitis (AIH), relapse after drug-withdrawal remains an unsolved dilemma and relapse rates as high as 90–95% are reported. A clear recommendation, when and in which patients to offer drug withdrawal is lacking. Moreover, there are no data on outcome in patients with mild disease activity in which therapy was withheld.

Recent Findings

In recent years, only a small number of studies addressed the question when and in which patients to stop treatment. Nevertheless, several potential predictors for early relapse could be identified including a prior relapse after drug withdrawal, dual immunosuppressive therapy at withdrawal, the presence of SLA/LP antibodies, and concomitant autoimmune diseases. Moreover, recent studies highlighted the relevance of complete biochemical remission defined as repeatedly normal serum transaminases and IgG levels.

Summary

Patients qualifying for treatment cessation should be in stable biochemical remission (complete normal serum transaminases and IgG levels) on immunosuppressive monotherapy for at least 2 years before an attempt of drug withdrawal is performed. An even longer treatment duration might be associated with a lower relapse risk. Patients with advanced liver disease should be advised against drug withdrawal, since a flare might cause hepatic decompensation. Finally, many patients strongly wish to perform a trial of drug withdrawal and in any case, it is more advisable to perform a controlled trail than having the patient is doing it secretly and thereby putting him at considerable risk. AIH is characterized by a fluctuating, relapsing disease course. Therefore, in our opinion, withholding treatment appears only defensible in very few patients with mild inflammatory activity on liver histology (mHAI < 4) and without relevant fibrosis. These patients must be closely followed up.

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