Case Report
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World J Gastroenterol. May 14, 2012; 18(18): 2287-2290
Published online May 14, 2012. doi: 10.3748/wjg.v18.i18.2287
Mycophenolate mofetil for maintenance of remission in steroid-dependent autoimmune pancreatitis
Jamie B Sodikoff, Steven A Keilin, Qiang Cai, Sheila J Bharmal, Melinda M Lewis, Gottumukkala S Raju, Field F Willingham
Jamie B Sodikoff, Steven A Keilin, Qiang Cai, Sheila J Bharmal, Field F Willingham, Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
Melinda M Lewis, Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322, United States
Gottumukkala S Raju, Department of Gastroenterology, the University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
Author contributions: Willingham FF contributed to study concept and design, and acquired data; Sodikoff JB, Lewis MM and Willingham FF analyzed and interpreted the data; Sodikoff JB and Willingham FF drafted the manuscript; Keilin SA, Cai Q, Lewis MM, Raju GS, Bharmal SJ and Willingham FF critically revised the manuscript for important intellectual content; Willingham FF provided administrative, technical and material support.
Supported by Department of Medicine, Emory University
Correspondence to: Field F Willingham, MD, MPH, Director of Endoscopy, Assistant Professor of Medicine, Emory University, 1365 Clifton Road, NW Building B, STE 1200, Atlanta, GA 30322, United States.
Telephone: +1-404-7783184 Fax: +1-404-7782925
Received: August 27, 2011
Revised: January 6, 2012
Accepted: April 10, 2012
Published online: May 14, 2012

Systemic corticosteroids represent the standard treatment for autoimmune pancreatitis with IgG4-associated cholangitis. For steroid-dependent disease, azathioprine has been used for maintenance of remission. Mycophenolate mofetil has been used for transplant immunosuppression and more recently for autoimmune hepatitis; however, there are no case reports to date on the use of mycophenolate mofetil in adult patients with autoimmune pancreatitis. A patient with IgG4-mediated autoimmune pancreatitis and IgG4-associated cholangitis refractory to steroids and intolerant of azathioprine was treated with mycophenolate mofetil, which inhibits de novo guanosine synthesis and blockade of both B and T lymphocyte production. Introduction of mycophenolate mofetil and uptitration to 1000 mg by mouth twice daily over a treatment period of 4 mo was associated with improvement in the patient’s energy level and blood glucose control and was not associated with any adverse events. The patient was managed without a biliary stent. However, there was a return of symptoms, jaundice, increase in transaminases, and hyperbilirubinemia when the prednisone dose reached 11 mg per day. In the first report of mycophenolate mofetil use in an adult patient with IgG4-associated autoimmune pancreatitis and IgG4-associated cholangitis, the introduction of mycophenolate mofetil was safe and well-tolerated without adverse events, but it did not enable discontinuation of the steroids. Mycophenolate mofetil and other immunomodulatory therapies should continue to be studied for maintenance of remission in the large subset of patients with refractory or recurrent autoimmune pancreatitis.

Keywords: Autoimmune diseases, Pancreatitis, Mycophenolate mofetil, Recurrence