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, 7 (8), 1073-1083

Risk Factors and Treatment of Relapses in Autoimmune Pancreatitis: Rituximab Is Safe and Effective

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Risk Factors and Treatment of Relapses in Autoimmune Pancreatitis: Rituximab Is Safe and Effective

Heithem Soliman et al. United European Gastroenterol J.

Abstract

Background and aims: Steroid therapy is the first-line treatment for autoimmune pancreatitis but relapses are frequent. The aims were to assess the efficacy and the safety of immunomodulator treatments for relapsing autoimmune pancreatitis and rituximab in particular and to identify relapsing risk factors.

Methods: Patients followed for autoimmune pancreatitis from 2000 to 2016 were included. Data were retrospectively analysed regarding autoimmune pancreatitis treatment.

Results: In total, 162 patients with autoimmune pancreatitis type 1 (n = 92) and type 2 (n = 70) were included (median follow-up: 3 years (0.5-14). Relapse occurred in 46.5% of patients with autoimmune pancreatitis type 1 (vs 19.3% in autoimmune pancreatitis 2; p < 0.001). Risk factors of relapse were cholangitis, initial use of steroids, other organ involvement and chronic pancreatitis in autoimmune pancreatitis type 1 and initial use of steroids, tobacco consumption and chronic pancreatitis for autoimmune pancreatitis type 2. Overall, 21 patients were treated with immunomodulators (azathioprine, n = 19, or methotrexate, n = 2) for relapses. The efficiency rate was 67%. A total of 17 patients were treated with rituximab, with two perfusions at 15 days apart. The efficacy was 94% (16/17), significantly better than immunomodulator drugs (p = 0.03), with a median follow-up of 20 months (11-44). Only two patients needed two supplementary perfusions.

Conclusion: In relapsing autoimmune pancreatitis, rituximab is more efficient than immunomodulator drugs and shows better tolerance.

Keywords: Autoimmune pancreatitis; IgG4 related disease; azathioprine; cholangitis; rituximab.

Figures

Figure 1.
Figure 1.
(a) Distribution of patient treatment according to the two auto-immune pancreatitis (AIP) subtypes and (b) Disease-free survival according to treatment: rituximab versus azathioprine.
Figure 2.
Figure 2.
(a) Biological evolution of liver enzymes in patients treated with rituximab. ALAT: alanine amino transaminase; ALP: alkaline phosphatase; GGT: gamma-glutamyl transferase; ULN: upper limit of normal. (b) Evolution of morphological features before and after azathioprine and rituximab. SC: sclerosing cholangitis; MPD: main pancreatic duct (including narrowing, long vanishing > 1/3 of MPD, multifocal vanishing, dilatation < 5 mm); CP: chronic pancreatitis.
Figure 3.
Figure 3.
: Magnetic resonance imaging (MRI) of a patient before and after rituximab treatment. (a) Axial T2, before treatment; diffuse pancreatic enlargement, ‘sausage-like’ appearance. (b) MRCP, before treatment; diffuse cholangitis with numerous typical biliary stenosis, mainly perihilar, stenosis of main pancreatic duct (MPD) upstream of the pancreas head. Typical MPD abnormalities: vanishing portion, without upstream enlargement, multiples, involving >1/3 of MPD. (c) Axial enhanced T1 after treatment; regression of pancreatic inflammation, pancreatic atrophy. (d) magnetic resonance – cholangiopancreatography (MRCP), after treatment; regression of cholangitis pattern biliary tree is normal, but appearance of chronic pancreatitis.

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  • Steroid Therapy and Steroid Response in Autoimmune Pancreatitis.
    Matsubayashi H, Ishiwatari H, Imai K, Kishida Y, Ito S, Hotta K, Yabuuchi Y, Yoshida M, Kakushima N, Takizawa K, Kawata N, Ono H. Matsubayashi H, et al. Int J Mol Sci. 2019 Dec 30;21(1):257. doi: 10.3390/ijms21010257. Int J Mol Sci. 2019. PMID: 31905944 Free PMC article. Review.

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