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Drug withdrawal led to relapse for patients with autoimmune hepatitis in remission

Almost all patients with autoimmune hepatitis in long-term remission experienced relapse or loss of remission after withdrawal of immunosuppressive therapy in a recent study.

The multicenter retrospective analysis included 131 patients with autoimmune hepatitis (AIH) whose treatment with corticosteroids and/or azathioprine was tapered off during 6 months or longer after 2 or more years of clinical and biochemical remission. Incidences of relapse (defined as serum alanine aminotransferase (ALT) levels three times greater than normal) and loss of remission (a rise in ALT levels requiring reinstitution of drug therapy) were recorded across a median follow-up of 8.8 years.

During the study, 61 participants experienced relapse and 56 loss of remission, while 14 participants sustained remission for 2 years or more after withdrawal. Of these patients, 57 were still in withdrawal, and 60 had fully stopped medication. The incidence rate for relapse or loss of remission was 59% of cases after 1 year, 73% at 2 years, 81% at 3 years and 88% at 5 years.

Eight of the patients who relapsed and two who experienced loss of remission progressed to fibrosis or cirrhosis during follow-up. All patients in a subgroup of 32 who underwent a subsequent attempt at discontinuing treatment after the initial failure experienced another relapse after a median of 10 months.

Investigators observed associations between increased relapse risk and concomitant autoimmune disease (HR=0.55; 95% CI, 0.37-0.83) and patients aged younger than 45 years at withdrawal (HR=1.53; 95% CI, 1.05-2.2) via multivariate analysis. Concomitant autoimmune disease was also associated with relapse or loss of remission within 1 year of withdrawal (P<.05).

“Our findings suggest that a reluctant attitude toward tapering or discontinuing [usually well-tolerated] low-dose immunosuppressive treatment is indicated in patients with AIH who have achieved clinical remission,” the researchers wrote. “Prospective studies are warranted to substantiate these observations.”