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Patient selection based on treatment duration and liver biochemistry increases success rates after treatment withdrawal in autoimmune hepatitis

Published:October 18, 2014DOI:https://doi.org/10.1016/j.jhep.2014.10.018

      Background & Aims

      In autoimmune hepatitis (AIH), relapse rates as high as 90% have been reported after treatment withdrawal. We therefore investigated, whether longer duration of treatment and proper patient selection could increase the long-term success rates after treatment withdrawal.

      Methods

      Following our previously published experience, treatment withdrawal was considered when biochemical remission was maintained under immunosuppressive monotherapy for at least 2 years. Remission was defined as repeatedly normal serum aminotransferase levels as well as normal IgG levels.

      Results

      Out of 288 patients with well-defined AIH, 28 patients were included. Median duration of treatment was 48.5 months (range 35–179) and a sustained remission was observed for 45 months (range 24–111). All patients were in remission on immunosuppressive monotherapy for a minimum of 2 years before treatment was withdrawn. Using this strict approach, 15 patients (54%) remained in long-term remission after a median of 28 months follow-up (range 17–57) and 13 patients (46%) required reinstitution of treatment. Higher ALT and IgG levels – although within the normal range in all patients – were associated with the time to relapse. All patients who remained in remission had ALT levels less than half the ULN and IgG levels not higher than 12 g/L at the time of treatment withdrawal.

      Conclusions

      Proper patient selection including a sustained complete biochemical remission on immunosuppressive monotherapy for a minimum of 2 years can markedly improve the success rates of treatment withdrawal. The interpretation of aminotransferase and IgG levels within the normal range could aid in predicting the risk of relapse.

      Graphical abstract

      Abbreviations:

      AIH (autoimmune hepatitis), AASLD (American Association of the Study of Liver Diseases), ALT (alanine-aminotransferase), IgG (immunoglobulin G), ANA (antinuclear antibody), SMA (smooth muscle antibody), LKM (liver kidney microsomal antibody), AMA (anti-mitochondrial antibody), SLA/LP (soluble liver antigen/liver-pancreas protein), AST (aspartate aminotransferase), INR (international normalized ratio), ULN (upper limit of normal), mHAI (modified histological activity index)

      Keywords

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