4.6 Article

Drug withdrawal in patients with autoimmune hepatitis in long-term histological remission: A prospective observational study

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EUROPEAN JOURNAL OF INTERNAL MEDICINE
卷 90, 期 -, 页码 30-36

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ELSEVIER
DOI: 10.1016/j.ejim.2021.03.024

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Autoimmune hepatitis; Treatment withdrawal; Histology; Remission

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In patients with autoimmune hepatitis (AIH) who achieve biochemical remission for at least 2 years, histological normalization may serve as a predictor for successful treatment withdrawal. Two-thirds of patients with histological normalization remained in remission during the follow-up period, while those with persistent histological inflammatory activity were unable to withdraw medication. More research is needed to identify predictors of relapse in these patients.
Background: Recommendations for drug withdrawal in patients with autoimmune hepatitis (AIH) in longstanding remission are conflicting and rely on retrospective data. We prospectively investigated the predictive value of histological normalisation for successful treatment withdrawal in AIH patients. Methods: Non-cirrhotic patients with established AIH and complete biochemical remission (normalisation of serum alanine aminotransferase [ALT] or aspartate aminotransferase [AST] and immunoglobulin G [IgG]) of at least 2 years were biopsied. Immunosuppressive therapy was only withdrawn in patients with histological normalisation (histological activity index [HAI] <= 3) with a minimum follow-up of 12 months. Results: A total of 17 patients in biochemical remission for at least 2 years were included. Persistent histological inflammatory activity (HAI >3) precluded drug withdrawal in five patients. These had higher values of ALT (25 vs. 16 U/L; p = 0.01) and AST (26 vs. 22 U/L; p = 0.01) compared with patients in histological remission. Immunosuppressive medication was withdrawn in 12 patients; eight (67%, C.I. 40-93% p = 0.4) remained in remission during a median follow-up of 62 months (range: 13-75 months); and four (33%, C.I. 7-60% p = 0.4) required reinstitution of therapy after 1, 6, 11, and 40 months, all without clinical signs of disease progression or hepatic decompensation. No predictors of relapse were identified. Conclusion: Two-thirds of the patients who prove to have histological normalisation after at least 2 years of biochemical remission achieve treatment-free remission. Although patient numbers were small and results should be interpreted with caution, these findings support a liver biopsy prior to drug withdrawal.

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