Editorial: Steroid‐Induced Diabetes in Autoimmune Hepatitis—A Call for Treatment Optimisation. Authors' Reply

We appreciate Dr. Pranab Barman's thoughtful and constructive editorial, ‘Steroid-Induced Diabetes in Autoimmune Hepatitis—A Call for Treatment Optimisation’, in response to our recent study on diabetes mellitus in autoimmune hepatitis (AIH) [1, 2]. We fully agree with his emphasis on minimising corticosteroid exposure to reduce the risk of steroid-induced diabetes. In our study, we reported a 13% incidence of new-onset diabetes in prednisolone-treated AIH, with particularly high incidence in the first year of treatment. Importantly, once diabetes developed, it usually persisted despite discontinuation or reduction of prednisolone. Diabetes was independently associated with development of cirrhosis and with worse overall survival. These findings reinforce the importance of minimising steroid burden in AIH management. That said, we would like to highlight the frequent difficulty in achieving steroid-free complete biochemical remission (CBR) in practice. As Dr. Barman noted, patients in our cohort were often maintained on low-dose prednisolone (median 10 mg/day) for 2–3 years prior to attempted withdrawal. While this may reflect historical practice, it also reflects the difficulty of sustaining remission with azathioprine monotherapy alone. In two recent retrospective cohort studies, only 25% and 27% of patients were off corticosteroids after 12 months [3, 4]. In a further large prospective European registry study, 44% of patients were steroid-free at 12 months, but just 27% maintained CBR [2, 5]. These findings demonstrate that, while minimising steroid exposure is a widely accepted goal, achieving it remains difficult in routine practice. Clinicians are often faced with complex decisions when tapering corticosteroids. CBR is not always attainable, and even when achieved, approximately 20% of patients relapse after steroid withdrawal despite ongoing steroid-sparing therapy [6, 7]. Yet prolonged corticosteroid use is clearly associated with metabolic complications, including diabetes, osteoporosis, and weight gain [8, 9]. Decision-making must consider the speed and stability of treatment response, tolerance to immunosuppressants, and patient preferences, all in the context of imperfect tools for predicting long-term remission. Thus, although recent guidelines recommend steroid withdrawal after 6–12 months of achieving remission [10], practice remains heterogeneous, with wide variation in steroid therapy duration across centres [11]. In our cohort and others, many patients required longer durations of corticosteroids due to intolerance to azathioprine, delayed remission, or disease relapse. There is a strong rationale for investigating novel steroid-sparing agents in AIH. Trials of biologic therapies or other targeted immunosuppressants are needed, particularly for patients with steroid dependence, refractory disease, or intolerance to existing regimens. We also need better predictive tools to identify which patients can safely withdraw from corticosteroids, thus allowing for more individualised tapering and follow-up strategies. Yours sincerely, (on behalf of all co-authors) Sarah Flatley: writing – original draft. The author has nothing to report. The author declarations of personal and financial interests are unchanged from those in the original article [1]. This article is linked to Flatley et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70188 and https://doi.org/10.1111/apt.70549. The author has nothing to report.