Autoimmune hepatitis: management of complex cases.

Autoimmune hepatitis (AIH) is a chronic immune-mediated inflammatory liver disease that may progress to cirrhosis, hepatic decompensation, and liver transplantation if not adequately controlled. Although standard therapy with corticosteroids and azathioprine (AZA) induces remission in the majority of patients, approximately 10–30% develop complex disease courses characterized by treatment intolerance, insufficient response, or severe acute presentations. The primary therapeutic goal is to achieve complete biochemical response (CBR), defined as normalization of serum transaminases and immunoglobulin G (IgG) levels, ideally within 6 months. This review addresses the management of refractory AIH, the use of second- and third-line therapies, and specific considerations in special populations, including pregnant women and patients with decompensated cirrhosis or metabolic dysfunction–associated steatotic liver disease (MASLD).