Monitoring

Patients with autoimmune hepatitis (AIH) require lifelong monitoring, as disease flares and relapses are frequent even after complete remission.[26] Progress is usually monitored by levels of serum aminotransferases, bilirubin, prothrombin time, albumin, and globulins (total or gamma globulin). Once remission is achieved and treatment withdrawn, patients should be closely monitored for relapse with regular laboratory assessments during the first 12 months and 6-12 monthly thereafter.[1][26]​​​ Follow-up liver biopsy should be undertaken if alanine aminotransferase and/or IgG levels increase or fluctuate. Follow-up biopsy is not always required to demonstrate histological remission prior to withdrawal of treatment, as the chances of significant inflammatory activity requiring increased immunosuppression are very low once transaminases and IgG levels have normalised. It is recommended, however, if a change of management is likely to result from the procedure; this is particularly the case in patients with sub-optimal response to immunosuppression, and in patients with treatment side effects. Biopsy is also advisable prior to withdrawal of treatment for patients who had a severe initial presentation and low tolerance of induction treatment, as histological findings are predictive of fibrosis progression and relapse.[26] Pre-withdrawal liver biopsy also is still strongly advised in children to ensure resolution of inflammation.[1]​ 

Patients on immunosuppressants must be monitored for potential complications of corticosteroid and azathioprine therapy. Full blood count for monitoring of leukopenia and thrombocytopenia, glucose levels, and renal function tests should be performed at regular intervals. Patients initiated on prednisolone/azathioprine combination therapy should have baseline clinical and laboratory parameters monitored during the first four weeks. As the steroid dose is tapered, monitoring intervals can be extended to 1-3 months. During maintenance treatment, patients should be seen at 3-6 month intervals.[26]

Eye examinations for cataracts and glaucoma are usually recommended in patients on high-dose and/or long-term corticosteroid therapy.

European guidelines advise that bone mineral density assessment (DEXA) should ideally be performed in all patients with AIH at presentation, along with follow-up assessment between 1 and 5 years, depending on outcome and general osteoporosis risk.[26]​ The US guidelines recommend that DEXA should be performed at baseline in those adult patients with AIH who have risk factors for osteoporosis, and repeated every 2-3 years of continuous glucocorticoid treatment.[1] They also advise that serum levels of 25-hydroxyvitamin D should be determined at diagnosis and annually thereafter, with insufficiency treated as required. Both guidelines recommend that patients should take vitamin D supplements and ensure adequate calcium intake while on glucocorticoid therapy. Bisphosphonate therapy is indicated for patients with AIH and documented osteoporosis.[1][26]​​

AIH patients with cirrhosis should undergo screening for hepatocellular carcinoma with 6 monthly ultrasound examination, with or without alpha-fetoprotein measurement.[1][26]

Changes in a patient’s mental health status should be monitored throughout management of AIH and their psychosocial needs addressed. Structured, validated questionnaires can be helpful.[1]​ Depression and anxiety are more common in patients with AIH than in the general population, mainly because of concerns about disease progression.[1][26] Depression is moderate in 19% of patients and moderately severe in 10%, and correlates strongly with physical fatigue.[1] Low scores on health-related quality of life assessments have been strongly associated with glucocorticoid use. Pre-treatment mental health problems, especially depression, may be intensified during glucocorticoid treatment.[80] The development or worsening of mental health problems may justify targeted counselling, individualised adjustments in the doses of glucocorticoids, or adjunctive antidepressant or anti-anxiety interventions.​​[1]

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