Autoimmune hepatitis isn’t something you catch from someone else. It’s not caused by alcohol, viruses, or poor diet. It happens when your own immune system turns against your liver, attacking it like it’s an invader. This isn’t rare-it affects 10 to 25 people per 100,000 globally, and women are four times more likely to develop it than men. The disease can strike at any age, but most cases appear in your 20s or 60s. Left untreated, it leads to scarring, liver failure, and the need for a transplant. The good news? We know how to stop it. And the backbone of treatment has been the same for over 50 years: steroids and azathioprine.
How Is Autoimmune Hepatitis Diagnosed?
There’s no single blood test that says, “Yes, this is autoimmune hepatitis.” Diagnosis is a puzzle. Doctors put together pieces from blood work, imaging, and a liver biopsy. The first clue? Abnormal liver enzymes. ALT and AST levels are often 5 to 10 times higher than normal. That’s a red flag. But so are many other liver conditions-viral hepatitis, fatty liver, drug reactions. So you need more.
Blood tests look for specific antibodies. Antinuclear antibodies (ANA) and smooth muscle antibodies (SMA) are the most common, found in about 80% of cases. These are called Type 1 AIH. A smaller group has LKM1 antibodies-Type 2 AIH. But here’s the big shift: as of the 2025 EASL guidelines, doctors no longer treat these types differently. Whether you have ANA or LKM1, the treatment plan is the same. The antibody type doesn’t change your outcome.
Another key marker is IgG, a type of antibody in your blood. If your IgG level is more than 1.5 times the normal upper limit, that’s another strong indicator. But none of this is enough on its own. The gold standard is a liver biopsy. A thin needle, guided by ultrasound, takes a tiny sample of liver tissue. Under the microscope, pathologists look for interface hepatitis-where immune cells are actively chewing through the border between liver tissue and the portal areas. This pattern is almost unique to autoimmune hepatitis. Without it, the diagnosis isn’t confirmed.
To help standardize things, doctors use the Revised International Autoimmune Hepatitis Group (IAIHG) scoring system. You get points for antibodies, IgG levels, liver histology, and by ruling out other causes like hepatitis B or C. A score over 15 means “probable” AIH. Over 20? That’s “definite.” This system keeps misdiagnoses low.
Why Steroids Are the First Line of Defense
When you’re diagnosed with autoimmune hepatitis, your immune system is running wild. Steroids like prednisone or prednisolone are powerful anti-inflammatories. They don’t cure the disease, but they shut down the attack on your liver fast. In fact, 80 to 90% of patients show improvement in liver enzymes within two weeks. That rapid response is actually part of the diagnosis-it’s rare for other liver diseases to react this quickly to steroids.
Standard treatment starts with a high dose: 0.5 to 1 mg per kilogram of body weight per day. For most people, that’s 30 to 60 mg daily. This isn’t meant to last forever. The goal is to bring the disease under control, then cut the dose slowly. By week 8, most patients are down to 10 to 15 mg per day. That’s the maintenance phase.
But steroids come with a cost. Seventy percent of people on steroid-only therapy develop side effects. Weight gain, facial puffiness (“moon face”), mood swings, insomnia, high blood sugar, and bone thinning are common. After five years, 15% develop diabetes, 20% get osteoporosis, and 10% develop cataracts. That’s why steroids are almost never used alone.
Azathioprine: The Steroid-Sparing Partner
Azathioprine-sold as Imuran or as a generic-is the quiet hero of AIH treatment. It’s an immunosuppressant. It doesn’t act fast like steroids, but it works over time to keep the immune system calm. When added to steroids, it lets doctors cut the steroid dose by 70 to 80% within six months. That means fewer side effects, better quality of life, and lower risk of long-term damage.
The typical starting dose is 50 mg per day, then increased to 1 to 2 mg per kg per day (up to 150 mg). It’s taken daily, often for years. But azathioprine isn’t risk-free. About 35% of patients get nausea or stomach upset. Around 12% develop bone marrow suppression, which can lower white blood cells and platelets. That’s why testing matters.
Before starting azathioprine, you should get tested for TPMT enzyme levels. TPMT breaks down azathioprine. If you have a genetic variant that makes you TPMT-deficient-which happens in about 0.3% of people-you’re at 30 times higher risk of life-threatening low blood counts. Testing costs $250 to $400 in the U.S., and while 78% of European centers do it routinely, only 45% of U.S. centers do. That’s a gap that needs fixing.
How Do You Know If Treatment Is Working?
It’s not enough to feel better. You need lab proof. Blood tests for ALT and AST are checked every 2 to 4 weeks at first. Then every 3 months. IgG levels are tracked quarterly. Normalization of these markers usually takes 18 to 24 months. That’s the definition of complete biochemical response-and it happens in 60 to 80% of patients.
But labs don’t tell the whole story. That’s why a repeat liver biopsy is recommended after 2 to 3 years of treatment. Biopsies show if the inflammation has truly healed. Histological remission-meaning no more interface hepatitis-is seen in 50 to 70% of patients. That’s the real goal: not just normal blood work, but a liver that’s healing.
Some patients don’t respond. About 20 to 40% have an incomplete response-ALT and AST stay above twice the normal limit. That’s when doctors switch to second-line drugs like mycophenolate mofetil or calcineurin inhibitors. In 10 to 15% of cases, treatment fails entirely, and transplant becomes the only option.
Can You Stop Treatment?
Many patients want to stop. They hate the side effects. They feel fine. But stopping too soon is dangerous. Studies show that 50 to 90% of patients relapse within months of stopping treatment. The 2025 EASL guidelines say: only consider stopping after 2 to 3 years of complete remission, confirmed by biopsy. And even then, you taper slowly-over 6 to 12 months. Only about 45% stay in remission two years after stopping. The other 55% come back with worse inflammation.
Relapses usually happen within 3 months of stopping. That’s why monitoring doesn’t stop when you feel better. Blood tests every 3 months for at least 2 years after stopping are essential.
What About Vaccines and Other Risks?
Because you’re on immunosuppressants, you’re more vulnerable to infections. That’s why hepatitis A and B vaccines are required before starting treatment. If you’re already infected with hepatitis B-even if it’s inactive-you’re at risk for reactivation. That’s why all patients get tested for hepatitis B surface antigen and core antibody before starting steroids or azathioprine. If you’re positive, you’ll need antiviral drugs like tenofovir to prevent liver damage from reactivation.
Also, avoid live vaccines while on treatment. The flu shot? Safe. Shingles vaccine? Not if you’re on immunosuppressants. Talk to your doctor before getting any vaccine.
What’s New in AIH Treatment?
The 2025 EASL guidelines were a major update. They dropped autoantibody subclassification, extended the treatment response window to 6-12 months, and emphasized biopsy for remission confirmation. But the biggest change? Recognition that patients need better support.
Many patients say steroid side effects are worse than the disease. One Reddit user described gaining 30 pounds of fluid in three weeks. Another developed pancreatitis from azathioprine. The 2024 Global Autoimmune Institute registry found 68% of patients had at least one treatment-related side effect.
New drugs are coming. Obeticholic acid (Ocaliva), originally for primary biliary cholangitis, is now in phase 3 trials for AIH and showed a 42% response rate. JAK inhibitors like tofacitinib and monoclonal antibodies targeting IL-6 are showing promise in early trials. Researchers are also testing microRNA blood panels that can predict steroid response within two weeks-something that could personalize treatment dramatically.
Genetic markers like HLA-DRB1*03:01 and *04:01 are linked to more severe disease. In the future, testing for these might help decide who needs aggressive therapy from day one.
What to Expect Long-Term
Autoimmune hepatitis is a lifelong condition for most. About 60 to 80% of patients need maintenance therapy indefinitely. But that doesn’t mean a poor quality of life. With proper management, many people live full, active lives. Biopsies show fibrosis can reverse-even from stage F3 to F0. One patient reported complete reversal after two years on 5 mg prednisone and 75 mg azathioprine.
Sticking to follow-up appointments, taking meds as prescribed, and reporting side effects early are the keys. You’re not just treating a disease-you’re protecting your liver for decades to come.
Can autoimmune hepatitis be cured?
Autoimmune hepatitis cannot be cured, but it can be controlled. With treatment, most people achieve remission, meaning inflammation stops and liver damage halts or reverses. Long-term medication is usually needed to keep the disease inactive. Stopping treatment too soon leads to relapse in most cases.
How long do you take azathioprine for autoimmune hepatitis?
Most patients take azathioprine for years, often indefinitely. It’s usually started alongside steroids and continued after steroids are tapered. If you achieve sustained remission for 2-3 years and have a normal biopsy, your doctor may consider stopping it slowly. But relapse is common, so many stay on it long-term to prevent flare-ups.
What are the most common side effects of prednisone for AIH?
Common side effects include weight gain, facial puffiness, mood swings, insomnia, high blood sugar (which can lead to diabetes), bone thinning (osteoporosis), high blood pressure, and cataracts. These are more likely with long-term use, which is why doctors combine prednisone with azathioprine to lower the steroid dose.
Do I need a liver biopsy if I feel fine?
Yes. You can feel fine while liver inflammation is still active. Blood tests can improve before the tissue heals. A repeat biopsy after 2-3 years of treatment is the only way to confirm histological remission-the true goal of treatment. Skipping it risks missing ongoing damage.
Is azathioprine safe if I want to get pregnant?
Azathioprine is considered one of the safest immunosuppressants during pregnancy. Many women with autoimmune hepatitis continue it while pregnant under close monitoring. Prednisone is also generally safe. Stopping treatment during pregnancy increases the risk of disease flare, which can harm both mother and baby. Always consult your hepatologist before planning pregnancy.
Why is hepatitis B testing required before starting treatment?
Immunosuppressants like steroids and azathioprine can reactivate dormant hepatitis B virus in people who’ve had it before-even if they never had symptoms. This can cause sudden, severe liver damage or even liver failure. Testing for hepatitis B surface antigen and core antibody is mandatory. If positive, antiviral drugs are started before immunosuppression begins.
What happens if I miss a dose of azathioprine?
Missing one dose occasionally won’t cause a flare, but consistent missed doses increase relapse risk. Azathioprine works over time to keep your immune system suppressed. If you miss multiple doses, your body may start attacking your liver again. If you miss a dose, take it as soon as you remember-but never double up. Talk to your doctor if you’re having trouble sticking to the schedule.
