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

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.

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.