Methotrexate as induction of remission the-rapy for IgG4-Related type 1 Autoimmune Pancreatitis

Context. Medium to high dose glucocorticoids represents the treatment of choice for inducing remission in IgG4-related type 1 autoimmune pancreatitis (IgGRD-AIP). However, in clinical settings where long-term corticosteroids treatment is contraindicated (e.g. diabetes and osteoporosis) alternative equally effective drugs would be recommendable. Objective. To assess the efficacy of methotrexate (MTX) as induction of remission therapy in selected cases of IgG4RD-AIP complicated by clinical scenarios that might advise against the use of corticosteroids. Methods. Three patients with active untreated IgG4RD-AIP were started on oral or subcutaneous MTX. Efficacy of MTX in inducing remission was assessed at 6 months by 18F-FDG PET/CT scan, IgG4-RD Responder Index (RI), serum IgG4 levels, and circulating plasmablasts (PBs). Results. All patients presented with exocrine pancreatic insufficiency; none had obstructive jaundice; all had overt diabetes. Baseline and post-treatment characteristics are presented in Table 1. After 6 months of MTX all patients were on complete remission with normal PBs and markedly improved PET findings. Conclusions. In some cases of IgG4RD-AIP with mild manifestations but with contraindications to glucocorticoids, MTX might represent a promising alternative strategy for inducing disease remission.