Inappropriate Long-Term Steroid Therapy in Autoimmune Hepatitis Might Cause the Development of Non-Alcoholic Fatty Liver Disease; A Challenging Situation

Implication for health policy/practice/research/medical education: This study is useful for gastroenterologists and hepatologists. which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Autoimmune hepatitis (AIH) is a chronic liver cell injury induced by immune mechanism. Steroid therapy +/-im-munosuppressive therapy is the mainstay of treatment in AIH (1). Insulin resistance and obesity are the harmful consequences of injustice steroid therapy. These conditions predispose the AIH patients to the development of concomitant non-alcoholic fatty liver disease (NAFLD). NAFLD is already considered as the hepatic manifestation of insulin resistance (metabolic) syndrome (2). The management of NAFLD differs from AIH with regard to steroid therapy. While steroid is lifesaving in AIH due to immune modulation effect, its long-term use worsen the course of NAFLD because the development of insulin resistance. The elevation of serum aminotransferase levels in AIH patients on steroid therapy does not necessarily mean treatment failure. The development of NAFLD might be considered as a cause. Considering the epidemic of obesity and increasing the incidence of NAFLD worldwide, this condition should be suspected in patients with any form of chronic hepatitis including AIH (3). We suggest the precise investigation for diagnosis, risk assessment, and the proper management of NAFLD in AIH patients before the start of steroid therapy. There are clinical and laboratory clues that refer to the existence of NAFLD in AIH patients. The increase of body weight, waist circumference, body mass index, fasting serum glucose, insulin, triglyceride, cholesterol, and low-density lipoprotein, in spite of normal serum gamma globulin level could suggest the evolution of NAFLD in AIH patients on steroid medication. Imaging modalities are non-invasive and acceptable options for the detection of NAFLD before starting ste-roid and in follow up visits. Unfortunately, liver ultraso-nography has limitation for the detection and staging of NAFLD especially in obese patients (4). However, proton magnetic resonance spectroscopy is a newer technique that is already considered as the gold standard imaging