August 2019 - Question 1

Q1. Correct answer: C 
 
Rationale: 
The two standard treatment regimens for AIH include corticosteroids (prednisone or prednisolone) alone, or corticosteroids combined with azathioprine. The combination regimen allows for a lower dose of steroids and fewer side effects with the same therapeutic efficacy. This patient appears to have developed azathioprine-induced pancreatitis, which is a rare complication more often seen in patients with Crohn's disease treated with azathioprine. In patients who are intolerant of azathioprine, mycophenolate mofetil and calcineurin inhibitors have been used with success.  
There are data supporting the use of budesonide in place of prednisone, but this regimen is not as effective in patients with cirrhosis or advanced fibrosis, so it is reserved for patients with lesser degrees of liver fibrosis. The TNF-alpha inhibitors are not used to treat AIH, nor is the IL-1 inhibitor anakinra. 
 
References: 
1. Czaja AJ. Diagnosis and management of autoimmune hepatitis: Current status and future directions. Gut Liver. 2016;10:177-203. 
2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Autoimmune Hepatitis. J Hepatol. 2015:63:971-1004. 
3. Manns MP, et al. Diagnosis and management of autoimmune hepatitis. Hepatology. 2010;51:1-31.

Q1. Correct answer: C 
 
Rationale: 
The two standard treatment regimens for AIH include corticosteroids (prednisone or prednisolone) alone, or corticosteroids combined with azathioprine. The combination regimen allows for a lower dose of steroids and fewer side effects with the same therapeutic efficacy. This patient appears to have developed azathioprine-induced pancreatitis, which is a rare complication more often seen in patients with Crohn's disease treated with azathioprine. In patients who are intolerant of azathioprine, mycophenolate mofetil and calcineurin inhibitors have been used with success.  
There are data supporting the use of budesonide in place of prednisone, but this regimen is not as effective in patients with cirrhosis or advanced fibrosis, so it is reserved for patients with lesser degrees of liver fibrosis. The TNF-alpha inhibitors are not used to treat AIH, nor is the IL-1 inhibitor anakinra. 
 
References: 
1. Czaja AJ. Diagnosis and management of autoimmune hepatitis: Current status and future directions. Gut Liver. 2016;10:177-203. 
2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Autoimmune Hepatitis. J Hepatol. 2015:63:971-1004. 
3. Manns MP, et al. Diagnosis and management of autoimmune hepatitis. Hepatology. 2010;51:1-31.

Q1. Correct answer: C 
 
Rationale: 
The two standard treatment regimens for AIH include corticosteroids (prednisone or prednisolone) alone, or corticosteroids combined with azathioprine. The combination regimen allows for a lower dose of steroids and fewer side effects with the same therapeutic efficacy. This patient appears to have developed azathioprine-induced pancreatitis, which is a rare complication more often seen in patients with Crohn's disease treated with azathioprine. In patients who are intolerant of azathioprine, mycophenolate mofetil and calcineurin inhibitors have been used with success.  
There are data supporting the use of budesonide in place of prednisone, but this regimen is not as effective in patients with cirrhosis or advanced fibrosis, so it is reserved for patients with lesser degrees of liver fibrosis. The TNF-alpha inhibitors are not used to treat AIH, nor is the IL-1 inhibitor anakinra. 
 
References: 
1. Czaja AJ. Diagnosis and management of autoimmune hepatitis: Current status and future directions. Gut Liver. 2016;10:177-203. 
2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Autoimmune Hepatitis. J Hepatol. 2015:63:971-1004. 
3. Manns MP, et al. Diagnosis and management of autoimmune hepatitis. Hepatology. 2010;51:1-31.