Letter: elderly AS‐AIH patients need more attention

Editors, We read the nationwide multicentre study by Téllez et al with great interest. It assessed the predictors of corticosteroid response in patients with acute severe autoimmune hepatitis (ASAIH).1 We applaud the novel and significant work of the authors. This is the largest retrospective cohort study evaluating the effect of corticosteroids on the prognosis of patients with ASAIH, and examining early predictors of treatment response. The researchers found that older patients with poor liver function during treatment were unlikely to show a positive response, and no liver function improvement after 7 days of corticosteroid therapy could identify treatment failure. As the International Autoimmune Hepatitis Group has also highlighted therapy of ASAIH,2 we consider this to be an opportunity to emphasise corticosteroid treatment in ASAIH. What duration of therapy response is preferable for evaluating treatment failure 7 or 14 days? Due to missing data, this study could not compare the SURFASA score on days three or seven of treatment. Previous studies or guidelines have proposed different durations, such as 7 ,3 144 or 7– 14 days,5 for evaluating corticosteroid response to conduct liver transplantation in a timely fashion. Hence, a comparative analysis of 7 and 14 days of therapy response in this study may offer a more comprehensive understanding of the appropriate time for liver transplantation. More importantly, older patients should be considered for AIH management since modern medical care faces the challenge of an ageing population, and there are agerelated differences in this disease. A systematic review reported that elderly patients with chronic AIH respond well to glucocorticoids and have fewer relapses after withdrawal of immunosuppressive treatment.6 In ASAIH, nonresponders are older than responders. Based on the existing large dataset, we anticipate the authors analysing response rate to corticosteroids for ASAIH in elderly subgroups. In addition, infection is an important concern for corticosteroid therapy in ASAIH. According to Yeoman et al, there was no statistically significant increase in sepsis occurrence in patients treated with corticosteroids compared with those without corticosteroids (6/23 = 26% vs. 1/9 = 11%, p = 0.64).7 Since Téllez et al also found similar rates of infection in patients who did and did not receive corticosteroids, this reduces lowers any concerns about of infection with therapy.