We read with great interest the article by Arvaniti et al. describing drug-induced autoimmune-like hepatitis (DI-ALH) in autoimmune hepatitis (AIH). The multicentre design and large sample size are important contributions to a field previously limited to case series or single-centre experiences [1]. By highlighting the clinical spectrum of DI-ALH and its overlap with idiopathic AIH, this study raises awareness of an under-recognised entity that is difficult to diagnose.
The retrospective design raises the possibility of misclassification. RUCAM and RECAM scores performed poorly in distinguishing DI-ALH from idiopathic AIH, with discriminatory ability close to chance. This questions the reliability of labelling cases as DI-ALH, especially when adjudication is retrospective. Nearly all patients received immunosuppression soon after diagnosis, precluding assessment of whether some cases might have resolved spontaneously. Reviews of drug-induced liver injury (DILI) emphasise the difficulty of separating autoimmune-like phenotypes from idiopathic AIH, underscoring the risk of diagnostic overlap [2].
The report that statins and herbal or dietary supplements were common exposures is notable. Yet causality is complex, given widespread statin use in populations with metabolic comorbidities. Recall bias and variability in supplement quality further limit reliability. Earlier work highlights that agents such as nitrofurantoin and α-methyldopa are established triggers, but the heterogeneity of newer agents makes causality harder to confirm [3].
Patients with DI-ALH presented with more acute, severe disease, higher transaminases and less baseline fibrosis than those with idiopathic AIH. This mirrors prior observations that acute severe AIH carries a distinct clinical profile and demands timely intervention to prevent poor outcomes [4]. The overlap in histology, combined with relapses in a subset of patients, supports the notion that drug exposures may unmask latent autoimmune disease rather than produce a discrete entity. Large cohort studies of drug-induced AIH show variability in disease course, with some cases evolving into chronic AIH [5].
The clinical dilemma is whether to withdraw the suspected agent before immunosuppression. In fulminant or severe presentations, delaying corticosteroids is unsafe and associated with a high risk [6]. In contrast, selected patients with milder disease may benefit from an initial trial of withdrawal, though data are limited. Observational studies suggest permanent treatment withdrawal can succeed in some AIH patients, raising the possibility of a similar approach in DI-ALH [7]. Without prospective evidence, management strategies remain uncertain.
Future work should build on the call for improved diagnostic approaches. Mechanistic studies suggest environmental agents may break immune tolerance in
Stigma, including perceived, enacted, and internalised forms, is associated with inflammatory bowel disease (IBD), affecting quality of life, delaying treatment, and impairing social interactions.
To summarise existing data on stigma related to IBD.
We searched MEDLINE, Embase and Scopus from inception to September 2025 for studies reporting the prevalence, assessment, predictors, and outcome of stigma in IBD.
We analysed 73 studies to explore stigma in IBD, its predictors and outcomes. There was significant heterogeneity in the methods of assessment of stigma due to the lack of standardised scales. Perceived stigma is common, with a prevalence rate of up to 85.6% in adults and 87% in children. Stigma manifests with concerns about being judged, body image issues, difficulties in relationships, and workplace discrimination. However, enacted and internal stigma are less frequently reported. Multiple predictors of stigma in IBD have been identified. Greater disease complexity and symptom frequency are associated with higher levels of perceived stigma. Low public awareness and knowledge of IBD contribute to increased stigma. These lead to psychological impacts such as anxiety and depression, social isolation and healthcare challenges, including reduced treatment adherence, ultimately reducing quality of life.
This highlights the heterogeneity in stigma assessment methods and the need for more standardised research. It also emphasises the importance of addressing stigma through increased awareness, support and interventions aimed at enhancing resilience and coping skills.
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