Autoimmune pancreatitis medical therapy
|
Autoimmune pancreatitis Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Autoimmune pancreatitis medical therapy On the Web |
|
American Roentgen Ray Society Images of Autoimmune pancreatitis medical therapy |
|
Risk calculators and risk factors for Autoimmune pancreatitis medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]
Overview
Medical Therapy
Role of Glucocorticoids:
- Preferred regimen : Prednisone is usually administered at an initial dose of 40 mg/d for 4 weeks followed by a taper of the daily dosage by 5 mg/wk depending upon the clinical parameters.
- Glucocorticoids are found to play an important role in the management of autoimmune pancreatitis via several ways such as:[1][2][3][4]
- Efficacy in alleviating symptoms
- Decreasing the size of the pancreas
- Reversing histopathologic features in patients with AIP
- Improvement of lab findings such as
- Resolution of hypergammaglobulinemia[5]
- Autoantibodies become undetectable
Response to Glucocorticoids:
- About 2/3rd of patients show good response to glucocorticoids with complete recovery.[6][7][8]
- Approximately 25% may require a second course of glucocorticoids.
- A few patients with autoimmune pancreatitis may require continuous treatment.
Response to Glucocorticoids in patients with Biliary strictures:
- Patients with biliary strictures have a variable response to glucocorticoids such as:[6][8][9][10][11]
- Patients with biliary strictures may respond to glucocorticoids.
- Patients with biliary strictures may not respond to glucocorticoids.
- Patients with biliary strictures may have an incomplete response to glucocorticoids.
- Patients with biliary strictures may require maintenance therapy with glucocorticoids to prevent relapse.
- Patients with biliary strictures may require maintenance therapy with glucocorticoids and/or immunomodulatory drugs to prevent relapse.
Monitoring of clinical parameters in patients on glucocorticoid therapy:
- Glucocorticoids are tapered depending upon following clinical parameters:[2][3][12][13]
- Relief of symptoms
- Serial changes in abdominal imaging of the pancreas and bile ducts
- Decreased serum γ-globulin and IgG4 levels
- Improvements in liver function tests
Role of Immunomodulatory drugs:
- Immunomodulatory drugs such as azathioprine are usually used when,
- AIP patients have no response to steroid management
- AIP patients relapse, if steroids are discontinued
- AIP patients cannot be weaned off steroids
- The monoclonal antibody, Rituximab, is found to be effective in the management of AIP but further studies are required for the recommendation of routine usage.
References
- ↑ Kamisawa T, Egawa N, Nakajima H, Tsuruta K, Okamoto A, Kamata N (2003). "Clinical difficulties in the differentiation of autoimmune pancreatitis and pancreatic carcinoma". Am. J. Gastroenterol. 98 (12): 2694–9. doi:10.1111/j.1572-0241.2003.08775.x. PMID 14687819.
- ↑ 2.0 2.1 Hirano K, Tada M, Isayama H, Yagioka H, Sasaki T, Kogure H, Nakai Y, Sasahira N, Tsujino T, Yoshida H, Kawabe T, Omata M (2007). "Long-term prognosis of autoimmune pancreatitis with and without corticosteroid treatment". Gut. 56 (12): 1719–24. doi:10.1136/gut.2006.115246. PMC 2095691. PMID 17525092.
- ↑ 3.0 3.1 Moon SH, Kim MH, Park DH, Hwang CY, Park SJ, Lee SS, Seo DW, Lee SK (2008). "Is a 2-week steroid trial after initial negative investigation for malignancy useful in differentiating autoimmune pancreatitis from pancreatic cancer? A prospective outcome study". Gut. 57 (12): 1704–12. doi:10.1136/gut.2008.150979. PMID 18583399.
- ↑ Ito T, Nakano I, Koyanagi S, Miyahara T, Migita Y, Ogoshi K, Sakai H, Matsunaga S, Yasuda O, Sumii T, Nawata H (1997). "Autoimmune pancreatitis as a new clinical entity. Three cases of autoimmune pancreatitis with effective steroid therapy". Dig. Dis. Sci. 42 (7): 1458–68. PMID 9246047.
- ↑ Hamano H, Kawa S, Horiuchi A, Unno H, Furuya N, Akamatsu T, Fukushima M, Nikaido T, Nakayama K, Usuda N, Kiyosawa K (2001). "High serum IgG4 concentrations in patients with sclerosing pancreatitis". N. Engl. J. Med. 344 (10): 732–8. doi:10.1056/NEJM200103083441005. PMID 11236777.
- ↑ 6.0 6.1 Ghazale A, Chari ST, Zhang L, Smyrk TC, Takahashi N, Levy MJ, Topazian MD, Clain JE, Pearson RK, Petersen BT, Vege SS, Lindor K, Farnell MB (2008). "Immunoglobulin G4-associated cholangitis: clinical profile and response to therapy". Gastroenterology. 134 (3): 706–15. doi:10.1053/j.gastro.2007.12.009. PMID 18222442.
- ↑ Raina A, Yadav D, Krasinskas AM, McGrath KM, Khalid A, Sanders M, Whitcomb DC, Slivka A (2009). "Evaluation and management of autoimmune pancreatitis: experience at a large US center". Am. J. Gastroenterol. 104 (9): 2295–306. doi:10.1038/ajg.2009.325. PMID 19532132.
- ↑ 8.0 8.1 Sandanayake NS, Church NI, Chapman MH, Johnson GJ, Dhar DK, Amin Z, Deheragoda MG, Novelli M, Winstanley A, Rodriguez-Justo M, Hatfield AR, Pereira SP, Webster GJ (2009). "Presentation and management of post-treatment relapse in autoimmune pancreatitis/immunoglobulin G4-associated cholangitis". Clin. Gastroenterol. Hepatol. 7 (10): 1089–96. doi:10.1016/j.cgh.2009.03.021. PMID 19345283.
- ↑ Chari ST, Smyrk TC, Levy MJ, Topazian MD, Takahashi N, Zhang L, Clain JE, Pearson RK, Petersen BT, Vege SS, Farnell MB (2006). "Diagnosis of autoimmune pancreatitis: the Mayo Clinic experience". Clin. Gastroenterol. Hepatol. 4 (8): 1010–6, quiz 934. doi:10.1016/j.cgh.2006.05.017. PMID 16843735.
- ↑ Kamisawa T, Egawa N, Nakajima H, Tsuruta K, Okamoto A (2004). "Morphological changes after steroid therapy in autoimmune pancreatitis". Scand. J. Gastroenterol. 39 (11): 1154–8. doi:10.1080/00365520410008033. PMID 15545176.
- ↑ Wakabayashi T, Kawaura Y, Satomura Y, Watanabe H, Motoo Y, Sawabu N (2005). "Long-term prognosis of duct-narrowing chronic pancreatitis: strategy for steroid treatment". Pancreas. 30 (1): 31–9. PMID 15632697.
- ↑ Maire F, Le Baleur Y, Rebours V, Vullierme MP, Couvelard A, Voitot H, Sauvanet A, Hentic O, Lévy P, Ruszniewski P, Hammel P (2011). "Outcome of patients with type 1 or 2 autoimmune pancreatitis". Am. J. Gastroenterol. 106 (1): 151–6. doi:10.1038/ajg.2010.314. PMID 20736934.
- ↑ Sahani DV, Sainani NI, Deshpande V, Shaikh MS, Frinkelberg DL, Fernandez-del Castillo C (2009). "Autoimmune pancreatitis: disease evolution, staging, response assessment, and CT features that predict response to corticosteroid therapy". Radiology. 250 (1): 118–29. doi:10.1148/radiol.2493080279. PMID 19017924.