Autoimmune hepatitis isn’t something you catch from someone else. It’s not caused by alcohol, viruses, or poor diet. It’s your own immune system turning against your liver. Think of it like a friendly fire incident inside your body - the soldiers meant to protect you start attacking your liver cells instead. This leads to ongoing inflammation, scarring, and if left untreated, cirrhosis or liver failure. The good news? We know how to stop it. And the backbone of that treatment has been the same for over 50 years: steroids and azathioprine.
How Do Doctors Know It’s Autoimmune Hepatitis?
There’s no single blood test that says, "Yes, this is autoimmune hepatitis." That’s why diagnosis is a puzzle. Doctors piece together clues from blood work, imaging, and a liver biopsy.
First, they check liver enzymes - ALT and AST. In active autoimmune hepatitis, these are often 5 to 10 times higher than normal. Then they look at IgG, a type of antibody. If it’s more than 1.5 times the upper limit of normal, that’s a red flag. Autoantibodies like ANA (antinuclear antibodies) or SMA (smooth muscle antibodies) are also common. About 80% of cases show these markers. A less common type, called type 2 AIH, has LKM1 antibodies, but it’s rare and doesn’t change how you’re treated.
Here’s the key: you have to rule out everything else. Viral hepatitis (A, B, C), alcohol-related damage, fatty liver disease, drug reactions - all of these can mimic autoimmune hepatitis. Blood tests for hepatitis B and C are mandatory before starting treatment. Why? Because if you have a hidden hepatitis B infection and start immunosuppressants, it can flare up dangerously.
The real gold standard is the liver biopsy. A small sample of liver tissue is taken using a thin needle guided by ultrasound. It’s low-risk - serious complications happen in less than 0.3% of cases. Under the microscope, pathologists look for something called interface hepatitis: inflammation right where the liver’s portal areas meet the healthy tissue. If this pattern shows up in at least 20 portal tracts, it’s almost certainly autoimmune hepatitis.
Doctors use a scoring system called the Revised IAIHG criteria. Points are added for symptoms, blood markers, biopsy findings, and excluding other causes. A score over 15 means probable AIH. Over 20? Definite AIH. No more guessing.
Why Steroids Are the First Line of Defense
Since the 1970s, corticosteroids like prednisone or prednisolone have been the go-to treatment. They work fast. In fact, 80 to 90% of patients show improved liver enzyme levels within two weeks. That’s not just a statistic - it’s a lifeline.
The typical starting dose is 0.5 to 1 mg per kilogram of body weight per day - up to 60 mg daily. For someone weighing 70 kg, that’s about 35 to 70 mg. It’s not a small amount. But it’s necessary to shut down the immune attack quickly.
Here’s the catch: steroids come with a heavy side effect list. Moon face. Weight gain. Mood swings. Insomnia. High blood sugar. Bone thinning. Cataracts. About 70% of people on steroid-only treatment develop at least one major side effect within five years. One patient on Reddit described it as "moon face that made me unrecognizable, 30 pounds of fluid weight in three weeks, and insomnia that felt like permanent jet lag."
That’s why steroids aren’t meant to be taken long-term alone. They’re the sledgehammer. The goal is to use them to get the disease under control, then get you off them as fast as safely possible.
Azathioprine: The Steroid-Sparing Partner
Azathioprine - sold under brand names like Imuran or as a generic - is the quiet hero in this story. It doesn’t work fast. It takes weeks to months to kick in. But it’s the reason you can survive long-term treatment.
Azathioprine is an immunosuppressant. It doesn’t kill immune cells - it slows them down. When combined with steroids, it allows doctors to cut the steroid dose by 70 to 80% within six months. That cuts side effects in half. Instead of 70% of patients suffering from steroid damage, it drops to 30%.
The starting dose is usually 50 mg per day, slowly 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 people get stomach issues - nausea, vomiting, diarrhea. Around 12% experience bone marrow suppression, which can drop white blood cell counts dangerously low. That’s why testing for TPMT enzyme levels is now standard before starting. TPMT is a liver enzyme that breaks down azathioprine. If you have a genetic variant that makes you TPMT-deficient (about 0.3% of people), even a normal dose can cause life-threatening toxicity. Testing costs $250-$400 in the U.S., and 89% of academic centers now do it routinely.
One patient shared on the American Liver Foundation forum: "Azathioprine caused pancreatitis at 100 mg. I had to switch to mycophenolate after 18 months of trial and error." That’s the reality - not everyone tolerates it. But for most, it’s the difference between living with side effects and living with a failing liver.
How Long Do You Take This Treatment?
There’s no fixed timeline. Some people feel better in months. Others take years.
Complete biochemical response - meaning ALT, AST, and IgG levels return to normal - happens in 60 to 80% of patients within 18 to 24 months. But that doesn’t mean you’re cured. It means the disease is controlled.
Doctors recommend a second liver biopsy after 2 to 3 years of treatment to check for histological remission - meaning the inflammation and scarring have actually reversed. Studies show 50 to 70% of patients achieve this. That’s huge. It means your liver can heal.
Here’s the hard truth: 60 to 80% of patients need lifelong maintenance therapy. Why? Because stopping treatment too soon leads to relapse in 50 to 90% of cases. Even if you feel fine, your liver might still be quietly inflamed.
Some patients do try to stop. The 2025 EASL guidelines say it’s okay - but only if you’ve had at least 2 years of complete remission, and you taper slowly over 6 to 12 months. Even then, 70% of relapses happen within three months of stopping. That’s why monitoring continues for life - liver tests every 3 months, even if you’re stable.
What If Steroids and Azathioprine Don’t Work?
Most people respond. But 10 to 15% don’t. That’s called treatment failure. Or maybe you can’t tolerate the side effects. That’s treatment intolerance.
When that happens, doctors turn to second-line drugs. Mycophenolate mofetil (CellCept) is the most common. It’s taken twice daily and tends to be easier on the stomach than azathioprine. It’s also less likely to cause bone marrow suppression. About 60% of patients who switch to mycophenolate see improvement.
Other options include calcineurin inhibitors like tacrolimus or cyclosporine. These are powerful and require careful blood level monitoring. They’re used when other drugs fail.
And there’s new hope on the horizon. The FDA gave obeticholic acid (Ocaliva) breakthrough therapy status in 2024 for AIH. In early trials, it showed a 42% complete response rate - better than the 28% with standard therapy. JAK inhibitors like tofacitinib and monoclonal antibodies targeting interleukin-6 are also in phase 2 trials. These aren’t available yet, but they’re coming.
What You Need to Do Before and During Treatment
Before starting steroids or azathioprine, you need a few things in place:
- Get tested for hepatitis B - if positive, you’ll need antiviral protection.
- Get vaccinated for hepatitis A and B - vaccines work poorly once you’re immunosuppressed.
- Have a TPMT test done - it’s non-negotiable before azathioprine.
- Get a bone density scan - steroids weaken bones. You may need calcium, vitamin D, or bisphosphonates.
- Start monitoring your blood sugar - steroids can trigger diabetes.
During treatment:
- Check liver enzymes every 2-4 weeks at first, then every 3 months.
- Get IgG levels checked quarterly.
- See your doctor if you get a fever, sore throat, or feel unusually tired - it could be low white blood cells.
- Take your meds at the same time every day. Missing doses increases relapse risk.
- Don’t drink alcohol. Ever.
And remember: this isn’t a sprint. It’s a marathon. The goal isn’t just to feel better. It’s to protect your liver for decades.
Real People, Real Results
Not everyone’s story is the same. One woman on HealthUnlocked wrote: "After 2 years on 5 mg prednisone + 75 mg azathioprine, my biopsy showed complete fibrosis reversal from F3 to F0." That’s not just hope - that’s science. The liver can regenerate. Even after scarring, treatment can undo damage.
Another patient said: "The side effects were worse than the disease." That’s true for many. But without treatment, the disease wins. With it, most people live full, normal lives. The 2025 EASL guidelines say the 10-year survival rate for treated AIH is over 90% - nearly the same as the general population.
The key is sticking with it. Even when it’s hard. Even when you feel fine. Even when the pills make you feel like a stranger in the mirror. Your liver is fighting for you. You just have to help it win.