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

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 2years. 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 48.5months (range 35–179) and a sustained remission was observed for 45months (range 24–111). All patients were in remission on immunosuppressive monotherapy for a minimum of 2years before treatment was withdrawn. Using this strict approach, 15 patients (54%) remained in long-term remission after a median of 28months 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 12g/L at the time of treatment withdrawal. Conclusions Proper patient selection including a sustained complete biochemical remission on immunosuppressive monotherapy for a minimum of 2years 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.