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2016 IAP国际共识：自身免疫性胰腺炎的治疗

已有 1945 次阅读 2017-3-28 07:15 |个人分类:临床指南和病例解析|系统分类:观点评述| 国际, style, color, 胰腺炎

2016 IAP国际共识：自身免疫性胰腺炎的治疗

CQ-1. What are the indications for treatment of AIP?
Consensus statements
A. “Symptomatic patients as follows are indication for treatment”: (level B).
Pancreatic involvement: e.g., obstructive jaundice, abdominal pain, back pain.
Other organ involvement (OOI): e.g., Jaundice due to bile duct stricture.
B. “Asymptomatic patients as follows are indication for treatment”: (level B).
Pancreatic: Persistent pancreatic mass on imaging.
OOI: Persistent liver test abnormalities in a patient with associated IgG4-related sclerosing cholangitis (IgG4-SC).

CQ-2. What is the best approach to inducton of remission?
Consensus statements
“For induction of remission, steroid is the first-line agent in all patients with active untreated AIP, unless if there are contraindications to steroid use.” (level A).
“In those with contraindications to steroid treatment, rituximab can induce remission as single agent. ” (level B).
“Except for rituximab, other steroid-sparing such as thiopurines are poorly effective as single agents for induction of remission. ”(level C).

CQ-3. Is biliary drainage needed in obstructive jaundice before treatment?
Consensus statements
“Biliary drainage is useful to prevent biliary infection and use of brushing and cytology can differentiate IgG4-SC from biliary malignancy. ” (level B).
“In some cases of mild jaundice without signs of infection, steroid treatment alone can be performed safely without biliary stenting. ” (level B).

CQ-4. What should be the minimum starting dose steroids for induction of remission?
Consensus statements
“Prednisone with the initial dose of 0.6-1.0 mg/kg/day should be started. ” (level A).
“A minimum of 20 mg/day is generally necessary to induce remission. ” (level B).

CQ-5. How to taper steroids?
Consensus statements
“Usually tapered by 5-10 mg/day every 1-2 weeks until a daily dosage of 20 mg, followed by tapering with 5 mg every 2 weeks.” (level B).
“Another acceptable regimen is 40 mg/day for 4 weeks followed by taper by 5 mg/week until off. ” (level B).
“Duration of total remission treatment should generally last 12 weeks. ” (level A).
“Very short duration (<4 weeks) of steroid induction treatment with a high dose of steroid 20 mg is not recommended. ” (level C).

CQ-6. Is maintenance treatment useful to prevent relapse of AIP?
Consensus statements
“The patients with type 1 AIP having low disease activity before treatment and those with type 2 do not need maintenance treatment. ” (level C).
“After successful induction of remission, maintenance therapy with low-dose glucocorticoids or steroid-sparing agents may be useful in some patients with type 1 AIP”. (level B).

CQ-7. Can we predict who will relapse?
Consensus statements
“Risk factors for relapsing remain poorly understood.”
“Some predictors of relapse include.
Remarkably high serum IgG4 levels (such as > x4 UNL) before treatment.
Persistently high serum IgG4 levels after steroid treatment.
Diffuse enlargement of the pancreas.
Proximal type of IgG4-SC.
Extensive multi-organ involvement (2xOOI) ” (level B).

CQ-8. How should relapse be treated ?
Consensus statements
“Although there is no “gold standard” for treatment in relapse cases, steroid and steroid-sparing agents such as immunemodulators or rituximab are useful. ” (level B)

CQ-9. Is surgical treatment useful?
Consensus statements
“Although steroid or alternative medications should be initially performed, surgical treatment may be useful in some refractory cases. ” (level B)