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Relapse After Treatment Withdrawal in Patients with Autoimmune Hepatitis

Serum AST, -globulin, and IgG levels, but not liver histology, predicted risk for relapse.

Treatment with prednisone, with or without azathioprine, triggers remission in most patients with autoimmune hepatitis (AIH). However, about 65% of these patients relapse after treatment withdrawal. Some experts advocate discontinuing treatment only in patients who exhibit normal histology during treatment, as evaluated by liver biopsies, but even patients with normal histology can relapse. In this study, investigators assessed additional factors that might help to predict which AIH patients can discontinue treatment safely.

At a single tertiary-care center in Minnesota, 132 patients (mean age, 46; 80% women) fulfilled international criteria for type 1 AIH. Patients were treated with either azathioprine plus prednisone (95 patients) or high-dose prednisone alone until they achieved remission, which was defined as absence of symptoms, aspartate transaminase (AST) levels lower than 2 times the upper limit of normal, and absence of interface hepatitis as evaluated by liver biopsy. Treatment was withdrawn during a 6-week period; laboratory testing was performed at baseline (treatment termination) and every 3 weeks for 3 months. Thereafter, follow-up was every 6 to 12 months.

Relapse occurred in 102 patients (77%) after treatment termination (mean duration to relapse, 10±2 months; range, 1–120 months). Compared with rates for patients who had normal laboratory values at baseline, relapse rates were higher in patients with abnormal serum AST (40% vs. 13%; P=0.008), -globulin (25% vs. 3%; P=0.009), or IgG levels (36% vs. 4%, P=0.001). Positive predictive values for these parameters, alone or in combination, ranged from 91% to 97%. Histologic findings at baseline were similar among patients who did or did not relapse.

Comment: In this retrospective study, abnormal serum AST, -globulin, and IgG levels were independent predictors of relapse after immunosuppressive therapy for AIH was discontinued. Surprisingly, histologic findings prior to discontinuing treatment were not predictive. Although the baseline laboratory parameters could be useful clinically for determining which AIH patients have the best chance of maintaining remission, AIH patients who are off therapy should be monitored carefully, because most patients will relapse eventually.

— Atif Zaman, MD, MPH

Published in Journal Watch Gastroenterology July 27, 2007

Citation(s):

Montano-Loza AJ et al. Improving the end point of corticosteroid therapy in type 1 autoimmune hepatitis to reduce the frequency of relapse. Am J Gastroenterol 2007 May; 102:1005-12.

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