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Quek HW, Page A, Lee K, Lee G, Hawthorne D, Clifford R, Potter K, Etherton-Beer C. The effect of deprescribing interventions on mortality and health outcomes in older people: An updated systematic review and meta-analysis. Br J Clin Pharmacol 2024; 90:2409-2482. [PMID: 39164070 DOI: 10.1111/bcp.16200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 08/22/2024] Open
Abstract
AIMS Previous systematic reviews suggest that deprescribing may improve survival, particularly in frail older people. Evidence is rapidly accumulating, suggesting a need for an updated review of the literature. METHODS We updated a 2016 systematic review and meta-analysis to include studies published from inception to 26 April 2024 from specified databases. Studies in which older people had at least one medication deprescribed were included and grouped by study designs and targeted medications. The risk of bias was assessed using the Cochrane tool and the Newcastle-Ottawa tool. Odds ratios (OR) or mean differences were calculated as the effect measures using either the Mantel-Haenszel or generic inverse-variance method with fixed- or random-effects meta-analyses. The primary outcome was mortality. Secondary outcomes were adverse drug withdrawal events, physical health, cognitive function, quality of life and effect on medication regimen. Subgroup analyses were performed based on age and intervention types. RESULTS A total of 259 studies (reported in 286 papers) were included in this updated review. Deprescribing polypharmacy did not result in a significant reduction in mortality in both randomized (OR 0.96, 95% confidence interval [CI] 0.84-1.09) and non-randomized studies (OR 0.70, 95% CI 0.36-1.38). Further subgroup analyses of randomized studies on deprescribing polypharmacy demonstrated a significant reduction in mortality in the young old (aged 65-79) (OR 0.71, 95% CI 0.51-0.99) and when patient-specific interventions were applied (OR 0.79, 95% CI 0.63-0.99). CONCLUSIONS Deprescribing can be achieved with potentially important benefits in terms of improved survival, particularly when patient-specific interventions are applied and initiated early in the young old.
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Affiliation(s)
- Hui Wen Quek
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Amy Page
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Kenneth Lee
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Georgie Lee
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Deborah Hawthorne
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Rhonda Clifford
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | | | - Christopher Etherton-Beer
- Western Australian Centre for Health and Ageing, The University of Western Australia and Royal Perth Hospital, Perth, Western Australia, Australia
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Hirano K, Sanga K, Natomi H, Niwa K. Hyperthyroidism and hypothyroidism in patients with autoimmune pancreatitis. Eur J Gastroenterol Hepatol 2024:00042737-990000000-00412. [PMID: 39324897 DOI: 10.1097/meg.0000000000002846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
OBJECTIVE The objective of this study is to clarify the clinical features of thyroid dysfunction observed in patients with autoimmune pancreatitis (AIP). METHODS We repeatedly examined thyroid function in 74 patients with type 1 AIP (58 males, 16 females; average onset age of AIP 67 years). Clinical and serological findings in patients with thyroid dysfunction were analyzed. RESULTS During follow-up, clinical and subclinical hypothyroidism were observed in 3 and 17 patients, respectively. Clinical and subclinical hyperthyroidism were observed in 5 and 1 patients, respectively. One patient showed clinical hyperthyroidism followed by subclinical hypothyroidism. All patients with clinical and subclinical hypothyroidism were asymptomatic and required no medical treatment, whereas four patients with clinical hyperthyroidism were symptomatic and received treatment with thiamazole. CONCLUSION Frequent hypothyroidism in AIP, which was previously reported, was confirmed. Moreover, in this study, the association between hyperthyroidism and AIP was demonstrated. Hyperthyroidism in AIP may be more clinically significant than hypothyroidism because patients frequently require medical treatment.
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Affiliation(s)
- Kenji Hirano
- Department of Internal Medicine, Japan Community Healthcare Organization Tokyo Takanawa Hospital
- Department of Gastroenterology, Tokyo Teishin Hospital, Tokyo, Japan
| | - Katsuyuki Sanga
- Department of Internal Medicine, Japan Community Healthcare Organization Tokyo Takanawa Hospital
| | - Hisayoshi Natomi
- Department of Internal Medicine, Japan Community Healthcare Organization Tokyo Takanawa Hospital
| | - Kazuhiro Niwa
- Department of Internal Medicine, Japan Community Healthcare Organization Tokyo Takanawa Hospital
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Tsujimae M, Masuda A, Takagi M, Kato T, Nakano R, Fujita K, Hirata Y, Kakuyama S, Furumatsu K, Nakagawa T, Ogisu K, Fujigaki S, Iemoto T, Ezaki T, Yagi Y, Ikegawa T, Yamanaka K, Sato Y, Juri N, Kobayashi T, Sakai A, Shiomi H, Sanuki T, Arisaka Y, Okabe Y, Kodama Y. Relapse and side effects of steroid therapy beyond 3 years in autoimmune pancreatitis: A multicenter retrospective study. Pancreatology 2024; 24:223-231. [PMID: 38320953 DOI: 10.1016/j.pan.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/12/2024] [Accepted: 01/14/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND The impact of extended steroid administration on patients with autoimmune pancreatitis after a 3-year maintenance period remains poorly understood. This study analyzed the advantage and disadvantage of continuing steroid therapy beyond 3 years. METHODS In this retrospective multicenter study across 17 institutions, patients who successfully completed 3 years of maintenance therapy without experiencing relapse were categorized into two groups: the maintenance therapy discontinuation group, who discontinued steroid therapy after the initial 3-year period, and maintenance therapy continuation group, who continued steroid therapy beyond 3 years. The cumulative relapse rate after 3 years of maintenance therapy was the primary outcome. Relapse predictors were compared using the Gray test for cumulative relapse incidence by specific factor. RESULTS Of 211 patients, 105 experienced no relapse during the 3-year maintenance therapy and were divided into two groups: 69 in the maintenance therapy discontinuation group and 36 in the maintenance therapy continuation group. The relapse rate was lower in the maintenance therapy continuation group than in the maintenance therapy discontinuation group (P = 0.035). Predictors of relapse after 3 years included cessation of maintenance therapy (hazard ratio [HR] = 3.76; 95 % confidence interval [CI] = 1.07-13.3, P = 0.040) and renal involvement (HR = 2.88; 95 % CI = 1.04-7.99, P = 0.042). The maintenance therapy continuation group showed a significantly higher prevalence of macrovascular complications, compared with the maintenance therapy discontinuation group (P = 0.005). CONCLUSIONS Cessation of steroid maintenance therapy and renal involvement were predictors of relapse after 3 years of maintenance therapy. However, the long-term use of steroids may increase the risk of macrovascular complications.
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Affiliation(s)
- Masahiro Tsujimae
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan.
| | - Megumi Takagi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Takao Kato
- Department of Gastroenterology, Hyogo Prefectural Awaji Medical Center, Sumoto, Japan
| | - Ryota Nakano
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Japan
| | - Koichi Fujita
- Department of Gastroenterology and Hepatology, Yodogawa Christian Hospital, Osaka, Japan
| | - Yuichi Hirata
- Department of Gastroenterology, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Saori Kakuyama
- Department of Gastroenterology, Takatsuki General Hospital, Takatsuki, Japan
| | - Keisuke Furumatsu
- Department of Gastroenterology, Akashi Medical Center, Akashi, Japan
| | - Takashi Nakagawa
- Department of Gastroenterology, Chibune General Hospital, Osaka, Japan
| | - Kyohei Ogisu
- Department of Gastroenterology, Nissei Hospital, Osaka, Japan
| | - Seiji Fujigaki
- Department of Gastroenterology, Hyogo Prefectural Harima Himeji Medical Center, Himeji, Japan
| | - Takao Iemoto
- Department of Gastroenterology, Kita-harima Medical Center, Ono, Japan
| | - Takeshi Ezaki
- Department of Gastroenterology, National Hospital Organization Kobe Medical Center, Kobe, Japan
| | - Yosuke Yagi
- Department of Internal Medicine, Shiso Municipal Hospital, Shiso, Japan
| | - Takuya Ikegawa
- Department of Gastroenterology, Japanese Red Cross Kobe Hospital, Kobe, Japan
| | - Kodai Yamanaka
- Department of Gastroenterology, Konan Medical Center, Kobe, Japan
| | - Yu Sato
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Japan
| | - Noriko Juri
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Japan
| | - Tsuyoshi Sanuki
- Department of Gastroenterology, Hyogo Prefectural Harima Himeji Medical Center, Himeji, Japan
| | | | - Yoshihiro Okabe
- Department of Gastroenterology, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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Chen S, Wang G, Wu L, Chen D, Fang K, Liu W, Xu B, Zhai YQ, Li M. Potential Added Value of 18F-FDG PET Metabolic Parameters in Predicting Disease Relapse in Type 1 Autoimmune Pancreatitis. BMC Gastroenterol 2024; 24:37. [PMID: 38233765 PMCID: PMC10792883 DOI: 10.1186/s12876-023-03113-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND The predictive value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) metabolic parameters for predicting AIP relapse is currently unknown. This study firstly explored the value of 18F-FDG PET/CT parameters as predictors of type 1 AIP relapse. METHODS This multicenter retrospective cohort study analyzed 51 patients who received 18F-FDG PET/CT prior to treatment and did not receive maintenance therapy after remission. The study collected baseline characteristics and clinical data and conducted qualitative and semi-quantitative analysis of pancreatic lesions and extrapancreatic organs. The study used three thresholds to select the boundaries of pancreatic lesions to evaluate metabolic parameters, including the maximum standard uptake value (SUVmax), mean standard uptake value (SUVmean), total lesion glycolysis (TLG), metabolic tumor volume (MTV), and tumor-to-normal liver standard uptake value ratio (SUVR). Univariate and multivariate analyses were performed to identify independent predictors and build a recurrence prediction model. The model was internally validated using the bootstrap method and a nomogram was created for clinical application. RESULTS In the univariable analysis, the relapsed group showed higher levels of SUVmax (6.0 ± 1.6 vs. 5.2 ± 1.1; P = 0.047), SUVR (2.3 [2.0-3.0] vs. 2.0 [1.6-2.4]; P = 0.026), and TLG2.5 (234.5 ± 149.1 vs. 139.6 ± 102.5; P = 0.020) among the 18F-FDG PET metabolic parameters compared to the non-relapsed group. In the multivariable analysis, serum IgG4 (OR, 1.001; 95% CI, 1.000-1.002; P = 0.014) and TLG2.5 (OR, 1.007; 95% CI, 1.002-1.013; P = 0.012) were independent predictors associated with relapse of type 1 AIP. A receiver-operating characteristic curve of the predictive model with these two predictors demonstrated an area under the curve of 0.806. CONCLUSION 18F-FDG PET/CT metabolic parameters, particularly TLG2.5, are potential predictors for relapse in patients with type 1 AIP. A multiparameter model that includes IgG4 and TLG2.5 can enhance the ability to predict AIP relapse.
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Affiliation(s)
- Shengxin Chen
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
- Graduate School, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Guanyun Wang
- Department of Nuclear Medicine, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
- Nuclear Medicine Department, Beijing Friendship Hospital, Capital Medical University, 95 Yong'an Road, Xicheng District, Beijing, 100050, China
| | - Lang Wu
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Dexin Chen
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Kaixuan Fang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Wenjing Liu
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Baixuan Xu
- Department of Nuclear Medicine, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ya-Qi Zhai
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Mingyang Li
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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Kourie M, Bogdanovic D, Mahmutyazicioglu K, Ghazi S, Panic N, Fjellgren E, Hellkvist L, Thiel T, Kjellman A, Kartalis N, Danielsson O, Dani L, Löhr JM, Vujasinovic M. Autoimmune Pancreatitis Type 1 with Biliary, Nasal, Testicular, and Pulmonary Involvement: A Case Report and a Systematic Review. J Clin Med 2023; 12:6340. [PMID: 37834983 PMCID: PMC10573784 DOI: 10.3390/jcm12196340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/16/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated condition associated with fibroinflammatory lesions that can occur at almost any anatomical site. It often presents as a multiorgan disease that may mimic malignancy, infection, or other immune-mediated conditions. Autoimmune pancreatitis (AIP) type 1 is the most prominent manifestation of IgG4-RD in the digestive tract, with common extra-pancreatic inflammation. We present the first patient with AIP and involvement of the testicles and nasal cavity. PATIENT AND METHODS A case of a patient with AIP type 1 and other organ involvement (bile ducts, testicles, nasal polyps, and lungs) is described. Additionally, a systematic review of AIP type 1 with testicular and nasal involvement was conducted. RESULTS The systematic review found two cases of AIP type 1 with testicular involvement and 143 cases with AIP type 1 with nasal cavity involvement. None of them had both testicular and nasal involvement. CONCLUSIONS This is the first case of AIP type 1 with other organ involvement, including testicular and nasal involvement, to be described. The number of patients with nasal and testicular involvement described in the literature is low. Creating awareness of this rare clinical condition is necessary, especially due to the very effective available treatment with corticosteroids and rituximab.
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Affiliation(s)
- Mourad Kourie
- Department of Medicine, Vrinnevisjukhuset, 603 79 Norrköping, Sweden;
| | - Darko Bogdanovic
- Department of Urology, Karolinska University Hospital, 141 86 Stockholm, Sweden; (D.B.); (T.T.); (A.K.)
| | - Kamran Mahmutyazicioglu
- Department of Radiology, Karolinska University Hospital, 141 86 Stockholm, Sweden; (K.M.); (N.K.)
| | - Sam Ghazi
- Department of Pathology, Karolinska University Hospital, 141 86 Stockholm, Sweden; (S.G.); (O.D.)
| | - Nikola Panic
- Digestive Endoscopy Unit, University Clinic “Dr Dragisa Misovic-Dedinje”, 11000 Belgrade, Serbia;
| | - Eva Fjellgren
- Medical Library, Karolinska University Hospital, 171 76 Stockholm, Sweden;
| | - Laila Hellkvist
- Department of Ear, Nose and Throat, Karolinska University Hospital, 171 76 Stockholm, Sweden;
| | - Tomas Thiel
- Department of Urology, Karolinska University Hospital, 141 86 Stockholm, Sweden; (D.B.); (T.T.); (A.K.)
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, 141 86 Stockholm, Sweden;
| | - Anders Kjellman
- Department of Urology, Karolinska University Hospital, 141 86 Stockholm, Sweden; (D.B.); (T.T.); (A.K.)
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, 141 86 Stockholm, Sweden;
| | - Nikolaos Kartalis
- Department of Radiology, Karolinska University Hospital, 141 86 Stockholm, Sweden; (K.M.); (N.K.)
| | - Olof Danielsson
- Department of Pathology, Karolinska University Hospital, 141 86 Stockholm, Sweden; (S.G.); (O.D.)
| | - Lara Dani
- Department of Rheumatology, Karolinska University Hospital, 141 86 Stockholm, Sweden;
| | - J.-Matthias Löhr
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, 141 86 Stockholm, Sweden;
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institute, 141 86 Stockholm, Sweden
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Kiyoshita Y, Ishii Y, Serikawa M, Hanada K, Sasaki T, Fujimoto Y, Yamaguchi A, Hirao K, Noma B, Minami T, Okazaki A, Yukutake M, Mouri T, Tsuboi T, Tatsukawa Y, Nakamura S, Hirano T, Ikemoto J, Saeki S, Tamura Y, Miyamoto S, Furukawa M, Nakmura K, Yamashita Y, Iijima N, Oka S. Relapse rate and predictors of relapse after cessation of glucocorticoid maintenance therapy in type 1 autoimmune pancreatitis: a multicenter retrospective study. BMC Gastroenterol 2023; 23:295. [PMID: 37667191 PMCID: PMC10478447 DOI: 10.1186/s12876-023-02939-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/29/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Type 1 autoimmune pancreatitis responds well to glucocorticoid therapy with a high remission rate. Moreover, glucocorticoid maintenance therapy can help prevent relapse. However, the relapse rate following cessation of long-term glucocorticoid therapy is unknown. The aim of this study was to clarify the relapse rate and predictors of relapse following long-term glucocorticoid therapy cessation. METHODS We analyzed 94 patients who achieved remission after undergoing glucocorticoid therapy, discontinued treatment after at least 6 months of maintenance therapy, and were subsequently followed up for at least 6 months. The patients were divided into three groups based on treatment duration (< 18, 18-36, and ≥ 36 months), and their relapse rates were compared. Univariate and multivariate analyses of clinical factors were conducted to identify relapse predictors. RESULTS After discontinuing glucocorticoid therapy, relapse was observed in 43 (45.7%) patients, with cumulative relapse rates of 28.2% at 1 year, 42.1% at 3 years, 47.0% at 5 years, and a plateau of 77.6% at 9 years. Of the 43 patients who relapsed, 25 (58.1%) relapsed within 1 year after after cessation of glucocorticoid therapy. Relapse and cumulative relapse rates did not differ significantly according to treatment duration. In the multivariate analysis, an elevated serum IgG4 level at the time of glucocorticoid cessation was found to be an independent predictor of relapse (hazard ratio, 4.511; p < 0.001). CONCLUSIONS A high relapse rate occurred after cessation of glucocorticoid maintenance therapy, regardless of the duration of maintenance therapy, especially within the first year after cessation. However, the normalization of long-term serum IgG4 levels may be a factor in considering cessation.
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Affiliation(s)
- Yusuke Kiyoshita
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yasutaka Ishii
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Masahiro Serikawa
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Hiroshima, Japan
| | - Tamito Sasaki
- Department of Gastroenterology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Yoshifumi Fujimoto
- Department of Gastroenterology, Hiroshima General Hospital, Hiroshima, Japan
| | - Atsushi Yamaguchi
- Department of Gastroenterology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Ken Hirao
- Department of Internal Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Bunjiro Noma
- Department of Gastroenterology, Kure Kyosai Hospital, Hiroshima, Japan
| | - Tomoyuki Minami
- Department of Gastroenterology, Hiroshima Red Cross & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Akihito Okazaki
- Department of Gastroenterology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Masanobu Yukutake
- Department of Gastroenterology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Teruo Mouri
- Department of Gastroenterology, Chugoku Rosai Hospital, Hiroshima, Japan
| | - Tomofumi Tsuboi
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yumiko Tatsukawa
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shinya Nakamura
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Tetsuro Hirano
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Juri Ikemoto
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Sho Saeki
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yosuke Tamura
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Sayaka Miyamoto
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Masaru Furukawa
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kazuki Nakmura
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yumiko Yamashita
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Noriaki Iijima
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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The Clinical Utility of Soluble Serum Biomarkers in Autoimmune Pancreatitis: A Systematic Review. Biomedicines 2022; 10:biomedicines10071511. [PMID: 35884816 PMCID: PMC9312496 DOI: 10.3390/biomedicines10071511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022] Open
Abstract
Autoimmune pancreatitis (AIP) is a rare etiological type of chronic pancreatitis. The clinical and radiological presentation of AIP often resembles that of pancreatic cancer. Identifying non-invasive markers for their early distinction is of utmost importance to avoid unnecessary surgery or a delay in steroid therapy. Thus, this systematic review was conducted to revisit all current evidence on the clinical utility of different serum biomarkers in diagnosing AIP, distinguishing AIP from pancreatic cancer, and predicting disease course, steroid therapy response, and relapse. A systematic review was performed for articles published up to August 2021 by searching electronic databases such as MEDLINE, Web of Science, and EMBASE. Among 5123 identified records, 92 studies were included in the qualitative synthesis. Apart from immunoglobulin (Ig) G4, which was by far the most studied biomarker, we identified autoantibodies against the following: lactoferrin, carboanhydrase II, plasminogen-binding protein, amylase-α2A, cationic (PRSS1) and anionic (PRSS2) trypsinogens, pancreatic secretory trypsin inhibitor (PSTI/SPINK1), and type IV collagen. The identified novel autoantigens were laminin 511, annexin A11, HSP-10, and prohibitin. Other biomarkers included cytokines, decreased complement levels, circulating immune complexes, N-glycan profile changes, aberrant miRNAs expression, decreased IgA and IgM levels, increased IgE levels and/or peripheral eosinophil count, and changes in apolipoprotein isoforms levels. To our knowledge, this is the first systematic review that addresses biomarkers in AIP. Evolving research has recognized numerous biomarkers that could help elucidate the pathophysiological mechanisms of AIP, bringing us closer to AIP diagnosis and its preoperative distinction from pancreatic cancer.
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Kubota K, Kamisawa T, Nakazawa T, Tanaka A, Naitoh I, Takikawa H, Unno M, Kawa S, Masamune A, Nakamura S, Okazaki K. Steroid therapy still plays a crucial role and could serve as a bridge to the next promising treatments in patients with IgG4-related sclerosing cholangitis: Results of a Japanese Nationwide Study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:884-897. [PMID: 35460190 DOI: 10.1002/jhbp.1157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The acceptable duration of steroid therapy for patients with IgG4-sclerosing cholangitis (SC) has been under debate. Our aim is to clarify the feasible duration of steroid treatment. DESIGN We retrospectively reviewed the data of patients with IgG4-SC and analyzed the following: biliary status during the steroid therapy, incidence of remission, relapse, relapse-free survival rate, and steroid-related complications (SRCs). RESULTS Remission was achieved 99.5% (763/767) of patients who received steroid therapy, while remission rate dropped to 63.6% (78/129) of patients who didn't receive it. Relapse was noted in 19.7% (151/763) of the patients who received steroid. Besides, relapse rate went up 38.4% (30/78) of the counterpart. Normalization of the serum total bilirubin and serum alkaline phosphatase (ALP) levels were achieved at two weeks regardless of biliary drainage. Multivariate analysis identified younger onset, MST less than three years, immunosuppressant, and steroid cessation as independent risk factors for relapse. Steroid-free was achieved in the patients underwent MST only 3.4% over 54 months. SRCs were recorded in a total of 99 patients (12.9%) despite sufficient preemptive medications. Multivariate analysis identified history of malignancy and immunosuppressant as independent risk factors for SRCs. CONCLUSION Steroid therapy should be continued for no less than three years to reduce the risk of relapse, with use of preemptive measures taken around five years. The biliary drainage might not be mandatory. Steroid as 1st line therapy could serve as a bridge to further promising treatments.
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Affiliation(s)
- Kensuke Kubota
- Endoscopic Unit, Yokohama City University Hospital, Yokohama, Japan
| | - Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan, Komagome Hospital, Tokyo, Japan
| | - Takahiro Nakazawa
- Department of Gastroenterology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Itaru Naitoh
- Department of Gastroenterology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hajime Takikawa
- Faculty of Medical Technology, Teikyo University, Tokyo, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shigeyuki Kawa
- Department of Internal Medicine, Matsumoto Dental University, Shiojiri, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Seiji Nakamura
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Kazuichi Okazaki
- Department of Internal Medicine, Kansai Medical University, Kori Hospital, Neyagawa, Japan
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9
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Beyer G, Hoffmeister A, Michl P, Gress TM, Huber W, Algül H, Neesse A, Meining A, Seufferlein TW, Rosendahl J, Kahl S, Keller J, Werner J, Friess H, Bufler P, Löhr MJ, Schneider A, Lynen Jansen P, Esposito I, Grenacher L, Mössner J, Lerch MM, Mayerle J. S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:419-521. [PMID: 35263785 DOI: 10.1055/a-1735-3864] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Georg Beyer
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Patrick Michl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Deutschland
| | - Wolfgang Huber
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Hana Algül
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Albrecht Neesse
- Klinik für Gastroenterologie, gastrointestinale Onkologie und Endokrinologie, Universitätsmedizin Göttingen, Deutschland
| | - Alexander Meining
- Medizinische Klinik und Poliklinik II Gastroenterologie und Hepatologie, Universitätsklinikum Würzburg, Deutschland
| | | | - Jonas Rosendahl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Stefan Kahl
- Klinik für Innere Medizin m. Schwerpkt. Gastro./Hämat./Onko./Nephro., DRK Kliniken Berlin Köpenick, Deutschland
| | - Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Jens Werner
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, Deutschland
| | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - Philip Bufler
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Deutschland
| | - Matthias J Löhr
- Department of Gastroenterology, Karolinska, Universitetssjukhuset, Stockholm, Schweden
| | - Alexander Schneider
- Klinik für Gastroenterologie und Hepatologie, Klinikum Bad Hersfeld, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Irene Esposito
- Pathologisches Institut, Heinrich-Heine-Universität und Universitätsklinikum Duesseldorf, Duesseldorf, Deutschland
| | - Lars Grenacher
- Conradia Radiologie München Schwabing, München, Deutschland
| | - Joachim Mössner
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Markus M Lerch
- Klinik für Innere Medizin A, Universitätsmedizin Greifswald, Deutschland.,Klinikum der Ludwig-Maximilians-Universität (LMU) München, Deutschland
| | - Julia Mayerle
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
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10
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Amendment of the Japanese consensus guidelines for autoimmune pancreatitis, 2020. J Gastroenterol 2022; 57:225-245. [PMID: 35192048 PMCID: PMC8938398 DOI: 10.1007/s00535-022-01857-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/28/2022] [Indexed: 02/04/2023]
Abstract
In response to the latest knowledge and the amendment of the Japanese diagnostic criteria for autoimmune pancreatitis (AIP) in 2018, the Japanese consensus guidelines for managing AIP in 2013 were required to be revised. Three committees [the professional committee for developing clinical questions (CQs) and statements by Japanese specialists; the expert panelist committee for rating statements by the modified Delphi method; and the evaluating committee of moderators] were organized. Twenty specialists in AIP extracted the specific clinical statements from a total of 5218 articles (1963-2019) from a search in PubMed and the Cochrane Library. The professional committee made 14, 9, 5, and 11 CQs and statements for the current concept and diagnosis, extra-pancreatic lesions, differential diagnosis, and treatment, respectively. The expert panelists regarded the statements as valid after a two-round modified Delphi approach with individually rating these clinical statements, in which a clinical statement receiving a median score greater than 7 on a 9-point scale from the panel was regarded as valid. After evaluation by the moderators, the amendment of the Japanese consensus guidelines for AIP has been proposed in 2020.
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11
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Yoon SB, Moon SH, Kim JH, Park JW, Kim SE, Kim MH. Determination of the duration of glucocorticoid therapy in type 1 autoimmune pancreatitis: A systematic review and meta-analysis. Pancreatology 2021; 21:S1424-3903(21)00474-9. [PMID: 34090808 DOI: 10.1016/j.pan.2021.05.303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The indications for maintenance glucocorticoid therapy (MGT) and its duration after initial remission of type 1 autoimmune pancreatitis (AIP) remain controversial. In contrast to the Japanese treatment protocol, the Mayo protocol does not recommend MGT after initial remission. This study aimed to evaluate the relapse rate in patients with type 1 AIP according to the duration of glucocorticoid therapy. METHODS We conducted a systematic literature review up until November 30, 2020, and identified 40 studies reporting AIP relapse rates. The pooled relapse rates were compared between groups according to the protocol and duration of glucocorticoids (routine vs. no MGT; glucocorticoids ≤6 months vs. 6-12 months vs. 12-36 months vs. ≥ 36 months). The pooled rates of adverse events related to glucocorticoids were also evaluated. RESULTS Meta-analysis indicated calculated pooled relapse rates of 46.6% (95% confidence interval (CI), 38.9-54.3%) with glucocorticoids for ≤ 6 months, 44.3% (95% CI, 38.8-49.8%) for 6-12 months, 34.1% (95% CI, 28.6-39.7%) for 12-36 months, and 27.0% (95% CI, 23.4-30.6%) for ≥ 36 months. The rate of relapse was also significantly lower in patients with routine-use protocol of MGT (31.2%; 95% CI, 27.5-34.8%) than in patients with no MGT protocol (44.1%; 95% CI, 35.8-52.4%). Adverse events were comparable between groups. CONCLUSIONS The rate of relapse tended to decrease with extended durations of glucocorticoid therapy up to 36 months. Clinicians may decide the duration of glucocorticoids according to patient condition, including comorbidities and risk of relapse.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea.
| | - Jong Hyeok Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Ji Won Park
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
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12
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Noguchi K, Nakai Y, Mizuno S, Hirano K, Kanai S, Suzuki Y, Inokuma A, Sato T, Hakuta R, Ishigaki K, Saito K, Saito T, Hamada T, Takahara N, Kogure H, Isayama H, Koike K. Role of Endoscopic Ultrasonography-Guided Fine Needle Aspiration/Biopsy in the Diagnosis of Autoimmune Pancreatitis. Diagnostics (Basel) 2020; 10:diagnostics10110954. [PMID: 33203118 PMCID: PMC7698022 DOI: 10.3390/diagnostics10110954] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022] Open
Abstract
Type 1 autoimmune pancreatitis (AIP) is histologically characterized by lymphoplasmacytic sclerosing pancreatitis (LPSP). Recently, the diagnostic yield of endoscopic ultrasonography-guided fine needle aspiration/biopsy (EUS-FNA/B) for AIP has been reported. However, its role in the diagnostic flow of AIP is not fully elucidated. We retrospectively reviewed 53 consecutive patients who were suspected with AIP and underwent EUS-FNA/B. We evaluated the contribution of EUS-FNA/B to the diagnosis of AIP before considering response to steroid therapy among patients with diffuse enlargement of the pancreas and those with focal enlargement, respectively. Twenty-two patients showed diffuse pancreatic enlargement and 31 showed focal enlargement. The final diagnosis was definitive AIP in 32 patients, probable AIP in 2, possible AIP in 1, and mass-forming focal pancreatitis in 18. There was no change in diagnosis after EUS-FNA/B among patients with diffuse pancreatic enlargement, while diagnosis changed in 38.7% (12/31) among those with focal enlargement—there was a probable to definitive diagnosis in 4 patients, unspecified to definitive in 3, and unspecified to probable in 5. EUS-FNB provided a significantly higher sensitivity for typical pathological findings of LPSP than EUS-FNA, and 10 patients were diagnosed as pathologically definitive AIP by EUS-FNB, though none were by EUS-FNA (p = 0.002). EUS-FNA/B was useful in the diagnosis of focal type AIP, and steroid therapy could be introduced after the diagnosis was confirmed. Meanwhile, EUS-FNA/B provided no contribution to diagnosis of diffuse type AIP. EUS-FNB showed a higher diagnostic yield than FNA.
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Affiliation(s)
- Kensaku Noguchi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Correspondence: ; Tel.: +81-3-3815-5411; Fax: +81-3-5800-8812
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Kenji Hirano
- Department of Gastroenterology, Tokyo Takanawa Hospital, Tokyo 108-8606, Japan;
| | - Sachiko Kanai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Yukari Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Akiyuki Inokuma
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo 113-8531, Japan;
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
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13
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Keidar E, Shermetaro J, Kwartowitz G. Pediatric Parotid Chronic Sclerosing Sialadenitis in an African-American Female: A Rare Case and Review of the Literature. Cureus 2020; 12:e8846. [PMID: 32754389 PMCID: PMC7386075 DOI: 10.7759/cureus.8846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Chronic sclerosing sialadenitis (CSS) or Küttner tumor is an under-recognized, benign fibroinflammatory disease most commonly seen in the submandibular gland of older adult males. Sialolithiasis or bacterial infection was first suspected as an etiology, but CSS is now considered an immunoglobulin G4-related disease (IgG4-RD). IgG4-RD can affect almost every organ in the body, characterized by organ fibrosis with IgG4-positive plasmacytes. Numerous autoimmune-related diseases have been unified under IgG4-RD, including Mikulicz disease (MD), autoimmune pancreatitis, Reidel’s thyroiditis, and others. In any organ, IgG4-RD can present similar to malignancy. Due to the ability to mimic malignancy, it is crucial to be aware of this under-recognized clinical entity. CSS is currently of broad and high clinical interest due to increased understanding, multiorgan involvement, and more clearly defined criteria. To increase awareness of this disease, we describe a rare presentation of CSS with a literature review.
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Affiliation(s)
- Eytan Keidar
- Otolaryngology - Head and Neck Surgery, McLaren Oakland Hospital, Pontiac, USA.,Medical Education, Michigan State University, East Lansing, USA
| | | | - Gary Kwartowitz
- Otolaryngology - Head and Neck Surgery, McLaren Oakland Hospital, Pontiac, USA
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14
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Management of biliary stricture in patients with IgG4-related sclerosing cholangitis. PLoS One 2020; 15:e0232089. [PMID: 32353060 PMCID: PMC7192452 DOI: 10.1371/journal.pone.0232089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background We aimed to determine the optimal approach with endoscopic biliary drainage (EBD) and corticosteroid (CS) for the treatment of IgG4-related sclerosing cholangitis (ISC). Methods To evaluate the safety of EBD for treatment of biliary stricture caused by ISC, we assessed the risk of stent dislodgement and sought to determine the most appropriate time for stent removal. We also assessed the safety of treatment with CS alone for patients with obstructive jaundice, and the rate of and risk factors for biliary tract complications. Results Sixty-nine patients with ISC treated with CS were enrolled. Twenty-eight patients (40.6%) were treated with EBD for biliary stricture before CS initiation. Intentional stent removal was performed in thirteen (46.4%) after confirming CS-induced improvement. Eleven of thirteen patients (84.6%) underwent stent removal within 1 month after CS initiation and all their stent removals were safely carried out without early (within two weeks) recurrence of obstructive jaundice. Ten of twenty-eight patients (35.7%) experienced spontaneous stent dislodgement after CS initiation, and seven (70%) of them developed stent dislodgement two weeks to two months after CS initiation. Among forty-one patients treated with CS alone without EBD, 10 patients had obstructive jaundice at the time of CS initiation and all of them achieved clinical improvement without biliary tract infection. During the follow-up, three patients (4.3%), all of whom had undergone EBD, developed bile-duct stones, while none of those treated with CS alone developed bile-duct stones (p = 0.032). Long-term biliary stenting was a risk factor for bile-duct stones. Conclusions Biliary stent removal should be carried out within 2 weeks after CS initiation if biliary stricture improves to prevent stent dislodgement. Obstructive jaundice can be treated safely with CS alone in patients without infection. Clinicians should be aware of the possibility of bile-duct stones in patients treated with EBD.
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15
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Masamune A, Kikuta K, Hamada S, Tsuji I, Takeyama Y, Shimosegawa T, Okazaki K. Nationwide epidemiological survey of autoimmune pancreatitis in Japan in 2016. J Gastroenterol 2020; 55:462-470. [PMID: 31872350 DOI: 10.1007/s00535-019-01658-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 12/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND To further clarify the clinico-epidemiological features of autoimmune pancreatitis (AIP) in Japan, we conducted the fourth nationwide epidemiological survey. METHODS This study consisted of two stage surveys; the number of AIP patients was estimated by the first survey and their clinical features were assessed by the second survey. We surveyed the AIP patients who had visited hospitals in 2016. RESULTS The estimated number of AIP patients in 2016 was 13,436, with an overall prevalence rate of 10.1 per 100,000 persons. The estimated number of newly diagnosed patients was 3984, with an annual incidence rate of 3.1 per 100,000 persons. Compared to the 2011 survey, both numbers more than doubled. We obtained detailed clinical information of 1474 AIP patients. The male-to-female sex ratio was 2.94, the mean age was 68.1, and mean age at diagnosis was 64.8. At diagnosis, 63% patients were symptomatic and nearly half of them presented jaundice. Pancreatic cysts were found in 9% of the patients and calcifications in 6%. Histopathological examination was performed in 64%, mainly by endoscopic ultrasonography-guided fine needle aspiration. Extra-pancreatic lesions were detected in 60% of the patients. Eighty-four % patients received the initial steroid therapy, and 85% received maintenance steroid therapy. Kaplan-Meier analysis revealed that the relapsed survival was 14% at 3 years, 25% at 5 years, 40% at 10 years, and 50% at 15 years. Mortality was favorable, but pancreatic cancer accounted for death in one quarter of fatal cases. CONCLUSION We clarified the current status of AIP in Japan.
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Affiliation(s)
- Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kazuhiro Kikuta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shin Hamada
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Ichiro Tsuji
- Division of Epidemiology, Department of Public Health and Forensic Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Kazuichi Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
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Noguchi K, Nakai Y, Mizuno S, Isayama H, Hirano K, Kanai S, Nakamura T, Uchino R, Takahara N, Kogure H, Tada M, Koike K. Insulin secretion improvement during steroid therapy for autoimmune pancreatitis according to the onset of diabetes mellitus. J Gastroenterol 2020; 55:198-204. [PMID: 31471733 DOI: 10.1007/s00535-019-01615-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/12/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Autoimmune pancreatitis (AIP) is frequently complicated by diabetes mellitus (DM), but DM associated with AIP is reported to improve after steroid therapy. The aim of this study is to investigate glucose intolerance during steroid therapy according to the onset of DM. METHODS Sixty-one patients who underwent steroid therapy for AIP were included into this study. We evaluated C peptide index (CPI), homeostasis model assessment for insulin resistance (HOMA-R), and the pancreatic diameter at AIP diagnosis and after 4 weeks, 1 year, and 2 years of steroid therapy. Patients were categorized into three groups according to DM onset: Pre-existing DM (pDM), concurrent DM (cDM), and non-DM (nDM). RESULTS Forty-three patients (71%) had DM: 15 pDM and 28 cDM. At AIP diagnosis, CPI was lower in patients with pDM (0.7, P = 0.007) and cDM (0.9, P = 0.018) than nDM (1.3). After 4 weeks of steroid therapy, CPI improved in cDM (P < 0.001) and in nDM (P = 0.021). After 2 years of steroid therapy, HOMA-R increased (2.1-3.0, P = 0.007) but CPI gradually improved (1.0-2.1, P = 0.004). DM improved in 23% of cDM, and 55% of insulin users in cDM discontinued using insulin. Pancreatic atrophy was seen in 30%, and was associated with DM. CONCLUSION DM in patients with AIP was associated with impaired insulin secretion rather than insulin resistance. Insulin secretion improved during steroid therapy for AIP in patients with concurrent DM. Thus, glucose intolerance can be an indication for AIP treatment.
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Affiliation(s)
- Kensaku Noguchi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kenji Hirano
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sachiko Kanai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomoka Nakamura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rie Uchino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Tacelli M, Celsa C, Magro B, Barresi L, Guastella S, Capurso G, Frulloni L, Cabibbo G, Cammà C. Risk Factors for Rate of Relapse and Effects of Steroid Maintenance Therapy in Patients With Autoimmune Pancreatitis: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2019; 17:1061-1072.e8. [PMID: 30312787 DOI: 10.1016/j.cgh.2018.09.051] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/20/2018] [Accepted: 09/22/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Risk for relapse after induction of remission with steroid therapy has been studied extensively in patients with autoimmune pancreatitis (AIP), but findings have been equivocal. We performed a systematic review and meta-analysis to estimate the relapse rate of AIP after initial remission after steroid treatment and to identify factors associated with relapse. METHODS Three reviewers searched MEDLINE, SCOPUS, and EMBASE until July 2018 to identify studies on rate of relapse of AIP after induction of remission with steroid therapy. A pooled estimate was calculated using the DerSimonian and Laird method for a random-effects model. This study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Thirty-six studies met the inclusion criteria for meta-analysis. The median follow-up time was 40.8 months. Fifty-two percent of patients were classified as having type 1 AIP. The pooled estimate of relapse rate was 33% (95% CI, 30%-37%). A higher proportion of patients with type 1 AIP had a relapse compared with patients with type 2 AIP (37.5% vs 15.9%; P < .001). We found significant heterogeneity among studies (P < .01). Long-term maintenance therapy with steroids and study quality were associated independently with AIP relapse, after we adjusted for year of publication by multivariate meta-regression. CONCLUSIONS In a systematic review and meta-analysis, we found that a large proportion of patients with AIP treated successfully with steroid induction therapy had a relapse (33%)-particularly patients with type 1 AIP (37%). Maintenance steroid therapy lasting longer than 1 year could reduce risk of relapse. However, the data characterizing relapse rates are of limited quality, indicating the need for randomized controlled trials and new immunosuppressive drugs.
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Affiliation(s)
- Matteo Tacelli
- Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine, University of Palermo, Palermo, Italy
| | - Ciro Celsa
- Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine, University of Palermo, Palermo, Italy
| | - Bianca Magro
- Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine, University of Palermo, Palermo, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Salvatore Guastella
- Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine, University of Palermo, Palermo, Italy
| | - Gabriele Capurso
- PancreatoBiliary Endoscopy and Endoscopic Ultrasonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute (Istituto di Ricovero e Cura a Carattere Scientifico), Vita Salute San Raffaele University, Milan, Italy
| | - Luca Frulloni
- Department of Medicine, Pancreas Institute, University of Verona, Verona, Italy
| | - Giuseppe Cabibbo
- Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine, University of Palermo, Palermo, Italy
| | - Calogero Cammà
- Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine, University of Palermo, Palermo, Italy.
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Kamisawa T, Nakazawa T, Tazuma S, Zen Y, Tanaka A, Ohara H, Muraki T, Inui K, Inoue D, Nishino T, Naitoh I, Itoi T, Notohara K, Kanno A, Kubota K, Hirano K, Isayama H, Shimizu K, Tsuyuguchi T, Shimosegawa T, Kawa S, Chiba T, Okazaki K, Takikawa H, Kimura W, Unno M, Yoshida M. Clinical practice guidelines for IgG4-related sclerosing cholangitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:9-42. [PMID: 30575336 PMCID: PMC6590186 DOI: 10.1002/jhbp.596] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IgG4‐related sclerosing cholangitis (IgG4‐SC) is a distinct type of cholangitis frequently associated with autoimmune pancreatitis and currently recognized as a biliary manifestation of IgG4‐related disease. Although clinical diagnostic criteria of IgG4‐SC were established in 2012, differential diagnosis from primary sclerosing cholangitis and cholangiocarcinoma is sometimes difficult. Furthermore, no practical guidelines for IgG4‐SC are available. Because the evidence level of most articles retrieved through searching the PubMed, Cochrane Library, and Igaku Chuo Zasshi databases was below C based on the systematic review evaluation system of clinical practice guidelines MINDS 2014, we developed consensus guidelines using the modified Delphi approach. Three committees (a guideline creating committee, an expert panelist committee for rating statements according to the modified Delphi method, and an evaluating committee) were organized. Eighteen clinical questions (CQs) with clinical statements were developed regarding diagnosis (14 CQs) and treatment (4 CQs). Recommendation levels for clinical statements were set using the modified Delphi approach. The guidelines explain methods for accurate diagnosis, and safe and appropriate treatment of IgG4‐SC.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan, Komagome Hospital, Tokyo, Japan
| | - Takahiro Nakazawa
- Department of Gastroenterology, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Susumu Tazuma
- Department of General Internal Medicine, Hiroshima University Graduate School of Biomedical & Health Science, Hiroshima, Japan
| | - Yoh Zen
- Department of Diagnostic Pathology, Kobe University, Kobe, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hirotaka Ohara
- Department of Community-Based Medical Education, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takashi Muraki
- Department of Medicine, Gastroenterology, Shinshu University, Matsumoto, Nagano, Japan
| | - Kazuo Inui
- Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Nagoya, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Takayoshi Nishino
- Department of Gastroenterology, Tokyo Womens' Medical University Yachiyo Medical Center, Yachiyo, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Atsushi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kensuke Kubota
- Department of Endoscopy, Yokohama City University Hospital, Yokohama, Japan
| | - Kenji Hirano
- Department of Gastroenterology, Tokyo Takanawa Hospital, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kyoko Shimizu
- Department of Gastroenterology, Tokyo Womens' Medical University, Tokyo, Japan
| | | | - Tooru Shimosegawa
- Division of Gastroenterology, South-Miyagi Medical Center, Ohgawara, Japan
| | - Shigeyuki Kawa
- Department of Internal Medicine, Matsumoto Dental University, Matsumoto, Japan
| | | | - Kazuichi Okazaki
- The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Moriguchi, Japan
| | - Hajime Takikawa
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Wataru Kimura
- Faculty of Medicine, Departments of Gastroenterology and Gastroenterological, General, Breast, and Thyroid Surgery, Yamagata University, Yamagata, Japan
| | - Michiaki Unno
- Division of Hepato-Biliary Pancreatic Surgery, Tohoku University Graduate School, of Medicine, Sendai, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health and Welfare, Ichikawa, Japan
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Majumder S, Mohapatra S, Lennon RJ, Piovezani Ramos G, Postier N, Gleeson FC, Levy MJ, Pearson RK, Petersen BT, Vege SS, Chari ST, Topazian MD, Witzig TE. Rituximab Maintenance Therapy Reduces Rate of Relapse of Pancreaticobiliary Immunoglobulin G4-related Disease. Clin Gastroenterol Hepatol 2018. [PMID: 29526692 DOI: 10.1016/j.cgh.2018.02.049] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS IgG4-related disease (IgG4-RD), a multi-organ fibroinflammatory syndrome, typically responds to steroids. However, some cases are steroid resistant, and pancreaticobiliary IgG4-RD commonly relapses after steroid withdrawal. Rituximab induces remission of IgG4-RD, but the need for and safety of maintenance rituximab treatment are unknown. We compared outcomes of patients with pancreaticobiliary IgG4-RD treated with or without maintenance rituximab therapy. METHODS We performed a retrospective study of patients with pancreaticobiliary IgG4-RD treated with rituximab at the Mayo Clinic in Rochester, Minnesota, from January 2005 through December 2015. The cohort was divided into patients who received only rituximab induction therapy (group 1, n = 14) and patients who received rituximab induction followed by maintenance therapy (group 2, n = 29). We collected data on recurrence of IgG4-RD symptoms and findings, as well as information on evaluations, treatment, and adverse events. RESULTS Median follow-up times were similar between group 1 (34 mo) and group 2 (27 mo) (P = .99). Thirty-seven patients (86%) were in steroid-free remission 6 months after rituximab initiation. A higher proportion of patients in group 1 had disease relapse (3-year event rate, 45%) than in group 2 (3-year event rate, 11%) (P = .034). Younger age, higher IgG4 responder index score after induction therapy, and increased serum levels of alkaline phosphatase at baseline or after rituximab induction were associated with relapse. Infections developed in 6 of 43 patients, all in group 2 (P = .067 vs group 1); all but 1 occurred during maintenance therapy. CONCLUSIONS In a retrospective study of patients with pancreaticobiliary IgG4-RD, we found rituximab maintenance therapy prolongs remission. Relapses are uncommon among patients receiving maintenance therapy, but maintenance therapy may increase risk of infection. Patients with factors that predict relapse could be candidates for rituximab maintenance therapy.
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Affiliation(s)
- Shounak Majumder
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sonmoon Mohapatra
- Department of Internal Medicine, Saint Peter's University Hospital, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, New Jersey
| | - Ryan J Lennon
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | | | - Neil Postier
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Randall K Pearson
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Thomas E Witzig
- Division of Hematology and Oncology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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20
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Abstract
Type 1 autoimmune pancreatitis (AIP) is an IgG-4-related systemic disease that can manifest as a pancreatic disorder or another disorder of presumed autoimmune origin. Type 2 disease is typically characterized by absent IgG-4-positive cells. As patients often present with acute pancreatitis, obstructive jaundice, or pancreatic mass, it is imperative to exclude malignancy, a more common diagnosis. AIP may respond to corticosteroids, and has a strong association with other immune-mediated diseases. Recent literature suggests the benefit of immune-modulating therapy, including rituximab, although no consensus exists. This review covers the essentials of diagnosis, but focuses primarily on management of AIP.
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Affiliation(s)
- Kamraan Madhani
- Department of Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA; Department of Medicine, Waterbury Internal Medicine Residency Program, Waterbury Hospital, Yale New Haven Hospital, Main 3, 64 Robbins Street, Waterbury, CT 06708, USA
| | - James J Farrell
- Section of Digestive Diseases, Yale University School of Medicine, Yale Center for Pancreatic Disease, Yale University, LMP 1080, 15 York Street, New Haven, CT 06510, USA.
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21
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Xin L, Meng QQ, Hu LH, Lin H, Pan J, Hao L, Liu PP, Qian W, Wang LW, Li ZS. Prediction and Management for Relapse of Type 1 Autoimmune Pancreatitis After Initial Steroid Treatment: A Long-Term Follow-up From China. Pancreas 2018; 47:1110-1114. [PMID: 30142120 DOI: 10.1097/mpa.0000000000001147] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aimed to investigate the frequency, predictors, and management of relapse of type 1 autoimmune pancreatitis (AIP) after steroid treatment. METHODS One hundred one patients with type 1 AIP receiving steroid as initial treatment were enrolled. Predictors were identified by multivariate analysis using Cox proportional hazards model. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated. RESULTS Thirty-nine (41.1%) patients experienced relapse after steroid treatment during a median follow-up of 40 months. The cumulative rate of relapse reached a plateau at 57.6% (95% CI, 50.3%-64.9%) at 59 months. Without maintenance therapy (HR, 4.53; 95% CI, 1.35-15.17) and proximal bile duct involvement (HR, 2.10; 95% CI, 1.07-4.14) were identified as risk factors. Repeated steroid treatment with the same initial dose but longer induction and tapering duration was given to 87.2% patients with relapse and obtained response (97.1%) during a short-term follow-up (median, 19 months). CONCLUSIONS Relapses are common in type 1 AIP after steroid treatment. Without maintenance therapy and proximal bile duct involvement were risk factors. Repeated steroid treatment with longer duration is effective for relapse.
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Affiliation(s)
- Lei Xin
- From the Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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22
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Abstract
OBJECTIVES Serum IgG4 level is a useful diagnostic marker of autoimmune pancreatitis (AIP); however, it is difficult to predict relapse. We investigated whether a change in serum IgG4 is predictive of AIP relapse during maintenance therapy. METHODS Seventy-three patients with AIP treated with steroids were divided into 3 groups according to their initial serum IgG4 levels: level 1 group (>2-fold upper limit), level 2 group (1- to 2-fold upper limit), and a normal group. The relapse rate and the prevalence of extrapancreatic lesions were compared between the 3 groups. The correlation between the relative rise of serum IgG4 levels and relapse during maintenance therapy was analyzed. RESULTS There were no differences in serum IgG4 levels in the presence or absence of relapse. The average number of extrapancreatic lesions was 1.02, 0.47, and 0.27 in level 1, level 2, and the normal group, respectively. The relative rise of serum IgG4 levels after steroid therapy was significantly higher in relapse than in nonrelapse cases. The area under the receiver operating characteristic curve of the relative rise of IgG4 levels for discriminating between the relapse and the nonrelapse cases was 0.85. CONCLUSIONS The relative rise of serum IgG4 levels after steroid therapy may provide an indication of relapse.
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23
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Kubota K, Kamisawa T, Hirano K, Hirooka Y, Uchida K, Ikeura T, Shiomi H, Ohara H, Shimizu K, Arakura N, Kanno A, Sakagami J, Itoi T, Ito T, Ueki T, Nishino T, Inui K, Mizuno N, Yoshida H, Sugiyama M, Iwasaki E, Irisawa A, Okazaki K, Kawa S, Shimosegawa T, Takeyama Y, Chiba T. Clinical course of type 1 autoimmune pancreatitis patients without steroid treatment: a Japanese multicenter study of 97 patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:223-230. [PMID: 29430861 DOI: 10.1002/jhbp.541] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sporadic autoimmune pancreatitis (AIP) cases showing remission without steroid treatment have been reported, however, the clinical course of these patients has not been clarified. This study sought to clarify the clinical course in AIP patients with hesitation for steroid treatment. METHODS We collected clinical data for AIP patients from high-volume centers in Japan. Data for AIP patients with and those without steroid treatment (steroid treatment vs. wait and see policy or W&S) were then compared. The primary point was the relapse-free survival rate (RFS) in patients with and those without steroid treatment, as determined using Kaplan-Meier curve. The secondary point was the identification of predictors of remission and risks of relapse in AIP patients without steroid treatment. RESULTS There were 510 AIP patients in the steroid treatment group and 97 patients in the W&S group. Overall, 55.7% (54/97) of type 1 AIP patients in the W&S group experienced transient remission without steroid treatment. The W&S group had a significantly higher patient age and significantly lower incidences of jaundice, diffuse pancreas swelling, proximal-type sclerosing cholangitis, and stent placement and a lower remission rate than the steroid treatment group (each P < 0.05). The RFS reached a plateau at 10 years in both the W&S group (50%) and steroid treatment group (52.9%). As for the RFS (W&S vs. group with steroid), 89.4% vs. 74.4% within 3 years, 81.8% vs. 65.3% within 5 years, and 50% vs. 52.9% within 10 years (log-rank, P = 0.064). Female gender (OR 0.340, P = 0.027) and stent placement for jaundice (OR 4.552, P = 0.008) were identified as predictors of transient remission in the W&S group. New-onset diabetes mellitus (OR 8.333, P = 0.012) and the presence of extensive multi-organ involvement (OR 35, P = 0.006) were identified as risks of relapse in the W&S group. CONCLUSION Some type 1 AIP patients without steroid treatment experience transient remission. These cases tend to have lower disease activities than AIP patients receiving steroids. Female gender and stent placement for jaundice may be predictors of transient remission among patients not receiving steroid treatment, however, relapses can occur in these patients with new-onset diabetes mellitus and the presence of extensive multi-organ involvement. Therefore, steroid treatment is still imperative for these patients.
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Affiliation(s)
- Kensuke Kubota
- Department of Endoscopy, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| | - Terumi Kamisawa
- Department of Internal Medicine, Tokyo Komagome Metropolitan Hospital, Tokyo, Japan
| | - Kenji Hirano
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Kazushige Uchida
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tsukasa Ikeura
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Osaka, Japan
| | - Hideyuki Shiomi
- Department of Gastroenterology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hirotaka Ohara
- Department of Community-based Medical Education, Nagoya City University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kyoko Shimizu
- Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Norikazu Arakura
- Department of Gastroenterology, Shinshu University Graduate School of Medicine, Matsumoto, Nagano, Japan
| | - Atsushi Kanno
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Junichi Sakagami
- Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takao Itoi
- Department of Gastroenterology, Tokyo Medical University, Tokyo, Japan
| | - Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Toshiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | - Takayoshi Nishino
- Department of Gastroenterology, Tokyo Women's Medical University, Yachiyo Hospital, Tokyo, Japan
| | - Kazuo Inui
- Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Toyoake, Aichi, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center, Nagoya, Aichi, Japan
| | - Hitoshi Yoshida
- Department of Gastroenterology, Showa University School of Medicine, Tokyo, Japan
| | - Masanori Sugiyama
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Kazuichi Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Osaka, Japan
| | - Shigeyuki Kawa
- Department of Gastroenterology, Shinshu University Graduate School of Medicine, Matsumoto, Nagano, Japan
| | - Toru Shimosegawa
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yoshifumi Takeyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
| | - Tsutomu Chiba
- Department of Gastroenterology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Goyal J, Barkin JA, Barkin JS. Randomised controlled trial of long-term maintenance corticosteroid therapy in patients with autoimmune pancreatitis. Gut 2018; 67:591. [PMID: 28601845 DOI: 10.1136/gutjnl-2017-314460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 05/16/2017] [Accepted: 05/20/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Jatinder Goyal
- Division of Gastroenterology, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Jodie A Barkin
- Division of Gastroenterology, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Jamie S Barkin
- Division of Gastroenterology, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
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25
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Miyazawa M, Takatori H, Shimakami T, Kawaguchi K, Kitamura K, Arai K, Matsuda K, Sanada T, Urabe T, Inamura K, Kagaya T, Mizuno H, Fuchizaki U, Yamashita T, Sakai Y, Yamashita T, Mizukoshi E, Honda M, Kaneko S. Prognosis of type 1 autoimmune pancreatitis after corticosteroid therapy-induced remission in terms of relapse and diabetes mellitus. PLoS One 2017; 12:e0188549. [PMID: 29166415 PMCID: PMC5699801 DOI: 10.1371/journal.pone.0188549] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/28/2017] [Indexed: 12/24/2022] Open
Abstract
Background and aim Relapse and diabetes mellitus (DM) are major problems for the prognosis of autoimmune pancreatitis (AIP). We examined the prognosis of type 1 AIP after corticosteroid therapy (CST)-induced remission in terms of relapse and DM. Methods The study enrolled 82 patients diagnosed with type 1 AIP who achieved remission with CST. We retrospectively evaluated the relapse rate in terms of the administration period of CST, clinical factors associated with relapse, and the temporal change in glucose tolerance. Results During follow-up, 32 patients (39.0%) experienced relapse. There was no significant clinical factor that could predict relapse before beginning CST. AIP patients who ceased CST within 2 or 3 years experienced significantly earlier relapse than those who had the continuance of CST (p = 0.050 or p = 0.020). Of the 37 DM patients, 15 patients (40.5%) had pre-existing DM, 17 (45.9%) showed new-onset DM, and 5 (13.5%) developed CST-induced DM. Patients with new-onset DM were significantly more likely to show improvement (p = 0.008) than those with pre-existing DM. Conclusions It was difficult to predict relapse of AIP based on clinical parameters before beginning CST. Relapse was likely to occur within 3 years after the beginning of CST and maintenance of CST for at least 3 years reduced the risk of relapse. The early initiation of CST for AIP with impaired glucose tolerance is desirable because pre-existing DM is refractory to CST.
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Affiliation(s)
- Masaki Miyazawa
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
- Department of gastroenterology, Keiju Medical Center, Nanao, Japan
- * E-mail:
| | - Hajime Takatori
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Tetsuro Shimakami
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kazunori Kawaguchi
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kazuya Kitamura
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kuniaki Arai
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Koichiro Matsuda
- Department of internal medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Taku Sanada
- Department of internal medicine, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Takeshi Urabe
- Department of gastroenterology, Public Central Hospital of Matto Ishikawa, Hakusan, Japan
| | - Katsuhisa Inamura
- Department of internal medicine, Tonami General Hospital, Tonami, Japan
| | - Takashi Kagaya
- Department of gastroenterology, National Hospital Organization Kanazawa Medical Center, Kanazawa, Japan
| | - Hideki Mizuno
- Department of gastroenterology, Toyama City Hospital, Toyama, Japan
| | | | - Taro Yamashita
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Yoshio Sakai
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Tatsuya Yamashita
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Eishiro Mizukoshi
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Masao Honda
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Shuichi Kaneko
- Department of gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
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Sakamoto A, Tanaka T, Hirano K, Koike K, Komuro I. Immunoglobulin G4-related Coronary Periarteritis and Luminal Stenosis in a Patient with a History of Autoimmune Pancreatitis. Intern Med 2017; 56:2445-2450. [PMID: 28824056 PMCID: PMC5643172 DOI: 10.2169/internalmedicine.8259-16] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Immunoglobulin G4 (IgG4)-related disease is a systemic inflammatory disorder that was first described in patients with autoimmune pancreatitis. Although IgG4-related disease is thought to involve the cardiovascular system, case reports describing coronary artery involvement are relatively rare. We describe a patient who was previously diagnosed with autoimmune pancreatitis and found to have coronary periarteritis and luminal narrowing. After the initiation of steroid treatment, the patient's coronary periarteritis and luminal stenosis were both ameliorated with an improvement in the serum IgG4 concentration. The present findings collectively suggest that IgG4-related immuno-inflammation may have a role in the development of coronary periarteritis and luminal atherosclerosis.
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Affiliation(s)
- Aiko Sakamoto
- Department of Cardiovascular Medicine, University of Tokyo Graduate School of Medicine, Japan
- Division for Health Service Promotion, University of Tokyo, Japan
| | - Tomofumi Tanaka
- Department of Cardiovascular Medicine, University of Tokyo Graduate School of Medicine, Japan
- Department of Cardiology, Sakakibara Heart Institute, Japan
| | - Kenji Hirano
- Department of Gastroenterology, University of Tokyo Graduate School of Medicine, Japan
- Department of Gastroenterology, Tokyo Takanawa Hospital, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, University of Tokyo Graduate School of Medicine, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, University of Tokyo Graduate School of Medicine, Japan
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Kubota K, Kamisawa T, Okazaki K, Kawa S, Hirano K, Hirooka Y, Uchida K, Shiomi H, Ohara H, Shimizu K, Arakura N, Kanno A, Sakagami J, Itoi T, Ito T, Ueki T, Nishino T, Inui K, Mizuno N, Yoshida H, Sugiyama M, Iwasaki E, Irisawa A, Shimosegawa T, Takeyama Y, Chiba T. Low-dose maintenance steroid treatment could reduce the relapse rate in patients with type 1 autoimmune pancreatitis: a long-term Japanese multicenter analysis of 510 patients. J Gastroenterol 2017; 52:955-964. [PMID: 28062947 DOI: 10.1007/s00535-016-1302-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 12/20/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND The effect of maintenance steroid treatment (MST) in reducing the risk of relapse in patients with autoimmune pancreatitis (AIP) remains under debate. The aim of this study was to validate the effect of MST on AIP administered in accordance with the 2010 Japanese consensus guidelines. METHODS The clinical data of patients with (n = 510) from 22 high-volume centers in Japan were studied. The primary endpoints were the relapse rates (RRs) in patients administered MST versus those not administered MST. The secondary endpoints were the optimal dose and duration of MST in terms of steroid toxicity and the predictors of relapse. RESULTS The RRs were 10.0% within 1 year, 25.8% within 3 years and 35.1% within 5 years. The RR in the steroid therapy group reached a plateau at 42.7% at 7 years. In terms of the optimal dosage, the overall RR in the MST 5 mg/day group was 26.1%, which was significantly lower than that in the group which had discontinued steroid therapy (45.2%; p = 0.023) or was receiving MST at 2.5 mg/day (43.4%, p = 0.001). The RRs in the group receiving MST at ≥5 mg/day versus the patient group receiving MST at <5 mg/day were 10.6 vs. 10.3% within 1 year, 23.5 vs. 32.9% within 3 years and 32.2 vs. 41.3% within 5 years, respectively (log-rank, p = 0.028). The best cutoff value of the total steroid dose for serious steroid toxicity was 6405 mg, with a moderate accuracy of 0.717 determined using the area under the curve. Presence of diffuse pancreatic swelling [odds ratio OR) 1.745; p = 0.008) and MST at >5 mg/day were identified as predictors of relapse (OR 0.483; p = 0.001). CONCLUSIONS The RR could continue to increase for 7 years even under MST. Based on our analysis of the side effects of steroid therapy, MST at 5 mg/day for 2 (total 4625 mg) to 3 (total 6425 mg) years might be a rational and safe therapeutic strategy in terms of keeping the RR to <30% while avoiding potential steroid toxicity.
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Affiliation(s)
- Kensuke Kubota
- Department of Endoscopy, Yokohama City University Hospital, Yokohama, Japan
| | - Terumi Kamisawa
- Department of Internal Medicine, Tokyo Komagome Metropolitan Hospital, Tokyo, Japan.
| | - Kazuichi Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Shigeyuki Kawa
- Center for Health, Safety and Environmental Management, Shinshu University, Matsumoto, Japan
| | - Kenji Hirano
- Department of Gastroenterology, Graduate School of Medicine, Tokyo University, Tokyo, Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Kazushige Uchida
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Hideyuki Shiomi
- Department of Gastroenterology, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Hirotaka Ohara
- Department of Community-Based Medical Education, Graduate School of Medicine, Nagoya City University, Nagoya, Japan
| | - Kyoko Shimizu
- Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Norikazu Arakura
- Department of Gastroenterology, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | - Atsushi Kanno
- Department of Gastroenterology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Junichi Sakagami
- Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takao Itoi
- Department of Gastroenterology, Tokyo Medical University, Tokyo, Japan
| | - Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Toshiharu Ueki
- Department of Gastroenterology, Chikushi Hospital, Fukuoka University, Fukuoka, Japan
| | - Takayoshi Nishino
- Department of Gastroenterology, Yachiyo Hospital, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuo Inui
- Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Toyoake, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center, Nagoya, Japan
| | - Hitoshi Yoshida
- Department of Gastroenterology, School of Medicine, Showa University, Tokyo, Japan
| | - Masanori Sugiyama
- Department of Surgery, School of Medicine, Kyorin University, Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Atshishi Irisawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Toru Shimosegawa
- Department of Gastroenterology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Yoshifumi Takeyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
| | - Tsutomu Chiba
- Gastroenterology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Abstract
Autoimmune pancreatitis (AIP) is a chronic fibroinflammatory disease of the pancreas that belongs to the spectrum of immunoglobulin G-subclass4-related diseases (IgG4-RD) and typically presents with obstructive jaundice. Idiopathic duct-centric pancreatitis (IDCP) is a closely related but distinct disease that mimics AIP radiologically but manifests clinically most commonly as recurrent acute pancreatitis in young individuals with concurrent inflammatory bowel disease. IgG4 levels are often elevated in AIP and normal in IDCP. Histologically, lymphoplasmacytic acinar inflammation and storiform fibrosis are seen in both. In addition, the histologic hallmark of IDCP is the granulocyte epithelial lesion: intraluminal and intraepithelial neutrophils in medium-sized and small ducts with or without granulocytic acinar inflammation often associated with destruction of ductal architecture. Initial treatment of both AIP and IDCP is with oral corticosteroids for duration of 4 weeks followed by a gradual taper. Relapses are common in AIP and relatively uncommon in IDCP, a relatively rare disease for which the natural history is not well understood. For patients with relapsing AIP, treatment with immunomodulators and more recently rituximab has been recommended. Although rare instances of pancreaticobiliary malignancy has been reported in patients with AIP, overall the lifetime risk of developing pancreatic cancer does not appear to be elevated.
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Affiliation(s)
- Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | | | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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29
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Outcome and Genetic Factors in IgG4-Associated Autoimmune Pancreatitis and Cholangitis: A Single Center Experience. Gastroenterol Res Pract 2017; 2017:6126707. [PMID: 28348580 PMCID: PMC5352972 DOI: 10.1155/2017/6126707] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/19/2017] [Accepted: 01/29/2017] [Indexed: 12/22/2022] Open
Abstract
Introduction. Most investigations on autoimmune pancreatitis (AIP) were published on Asian cohorts while those on Caucasians are limited. However, there might be differences related to the origin. Patients and Methods. We analyzed 36 patients and compared type 1 (AIP1) with type 2 (AIP2). Results. The majority of patients suffered from AIP1 (55.6%). AIP1 patients were significantly older than AIP2 patients (54.4 versus 40.8 years). Moreover, 85.0% of AIP1 patients had concurrent autoimmune cholangitis (AIC) while 18.8% of AIP2 patients suffered from overlap to ulcerative colitis (UC). However, AIP1 patients revealed a cholestatic course and had significantly higher immunoglobulin G4 levels (IgG4). When compared to allele frequencies in healthy controls, in patients with AIP1 HLA-B8 reached statistical significance. Response to steroids was excellent in both groups, but we noticed high rates of relapse especially in AIP1 patients. Finally, 3 patients with AIP1 were diagnosed with cholangiocellular carcinoma (CCC). Conclusion. In contrast to Asian studies, we found an almost equal distribution of AIP1 and AIP2 patients in our German cohort. AIP2 patients were younger and mostly of female gender whereas AIP1 patients revealed higher IgG4 levels and involvement of the biliary tract in sense of IgG4-associated cholangitis.
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30
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Masamune A, Nishimori I, Kikuta K, Tsuji I, Mizuno N, Iiyama T, Kanno A, Tachibana Y, Ito T, Kamisawa T, Uchida K, Hamano H, Yasuda H, Sakagami J, Mitoro A, Taguchi M, Kihara Y, Sugimoto H, Hirooka Y, Yamamoto S, Inui K, Inatomi O, Andoh A, Nakahara K, Miyakawa H, Hamada S, Kawa S, Okazaki K, Shimosegawa T. Randomised controlled trial of long-term maintenance corticosteroid therapy in patients with autoimmune pancreatitis. Gut 2017; 66:487-494. [PMID: 27543430 DOI: 10.1136/gutjnl-2016-312049] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/23/2016] [Accepted: 07/26/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Corticosteroid has been established as the standard therapy for autoimmune pancreatitis (AIP), but the requirement for maintenance corticosteroid therapy is controversial. We conducted a randomised controlled trial to clarify the efficacy of maintenance corticosteroid therapy in patients with AIP. DESIGN We conducted a multicentre, tertiary setting, randomised controlled trial. After the induction of remission with the initial oral prednisolone (PSL) treatment, maintenance therapy with PSL at 5-7.5 mg/day was continued for 3 years or withdrawn at 26 weeks. The primary endpoint was relapse-free survival over 3 years and the secondary endpoint was serious corticosteroid-related complications. All analyses were performed on an intention-to-treat basis. RESULTS Between April 2009 and March 2012, 49 patients with AIP were randomly assigned to the maintenance therapy group (n=30) or the cessation group (n=19). Baseline characteristics were not different between the two groups. Relapses occurred within 3 years in 11 out of 19 (57.9%) patients assigned to the cessation group, and in 7 of 30 (23.3%) patients in the maintenance therapy group. The relapse rate over 3 years was significantly lower in the maintenance therapy group than that in the cessation group (p=0.011). The relapse-free survival was significantly longer in the maintenance therapy group than that in the cessation group (p=0.007). No serious corticosteroid-related complications requiring discontinuation of PSL were observed. CONCLUSIONS Maintenance corticosteroid therapy for 3 years may decrease relapses in patients with AIP compared with those who discontinued the therapy at 26 weeks. TRIAL REGISTRATION NUMBER UMIN000001818; Results.
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Affiliation(s)
- Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Kazuhiro Kikuta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ichiro Tsuji
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tatsuo Iiyama
- Integrated Center for Advanced Medical Technologies (ICAM-Tech), Kochi Medical School, Kochi, Japan
| | - Atsushi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuichi Tachibana
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Kazushige Uchida
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Hideaki Hamano
- Medical Informatics Division and Internal Medicine, Gastroenterology, Shinshu University Hospital, Matsumoto, Japan
| | - Hiroaki Yasuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Junichi Sakagami
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akira Mitoro
- Department of Gastroenterology, Endocrinology and Metabolism, Nara Medical University, Nara, Japan
| | - Masashi Taguchi
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | | | - Hiroyuki Sugimoto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Satoshi Yamamoto
- Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Nagoya, Japan
| | - Kazuo Inui
- Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Nagoya, Japan
| | - Osamu Inatomi
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Kazuyuki Nakahara
- Department of Gastroenterology, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Hiroyuki Miyakawa
- Department of Bilio-Pancreatology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Shin Hamada
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shigeyuki Kawa
- Center for Health, Safety, and Environmental Management, Shinshu University, Matsumoto, Japan
| | - Kazuichi Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
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31
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Ikeura T, Miyoshi H, Shimatani M, Uchida K, Takaoka M, Okazaki K. Long-term outcomes of autoimmune pancreatitis. World J Gastroenterol 2016; 22:7760-7766. [PMID: 27678359 PMCID: PMC5016376 DOI: 10.3748/wjg.v22.i34.7760] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/04/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Autoimmune pancreatitis (AIP) has been considered a favorable-prognosis disease; however, currently, there is limited information on natural course of AIP during long-term follow-up. Recently published studies regarding the long-term outcomes of AIP has demonstrated the developments of pancreatic stone formation, exocrine insufficiency, and endocrine insufficiency are observed in 5%-41%, 34%-82%, and 38%-57% of patients having the disease. Furthermore, the incidence rate of developing pancreatic cancer ranges from 0% to 4.8% during the long-term follow-up. The event of death from AIP-related complications other than accompanying cancer is likely to be rare. During follow-up of AIP patients, careful surveillance for not only relapse of the disease but also development of complications at regular intervals is needed.
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