Hepatitis C and autoimmune hepatitis: What gets treated first?

The coexistence of chronic hepatitis C (CHC) and autoimmune hepatitis (AIH) creates a clinical dilemma. Histologic features may suggest the predominance of one versus the other. Nevertheless, histologic differences are not absolute. Immunosuppressive therapy may be used as frontline treatment for patients with predominant histologic features of AIH. In the absence of clinical and biochemical improvement, interferon should not be withheld and a trial of antiviral therapy should be considered. Interferon can be frontline therapy for patients with the overlap syndrome, if histologic features of CHC predominate, a low titer of autoantibodies is present, and coexistent autoimmune diseases are absent. No matter what treatment is offered, close monitoring during the course of treatment is a necessity.