title: Tacrolimus as a reasonable alternative in a patient with steroid-dependent and thiopurine-refractory autoimmune pancreatitis with IgG4-associated cholangitis.
abstract: BACKGROUND
  More recently, autoimmune pancreatitis (AIP) in association with IgG4-positive cholangitis (IAC) has been recognised as a new and challenging entity. Currently, initiation of high dose steroids (e.g., prednisolone 0.5 - 1 mg/kg/day) followed by a steroid dose taper in combination with purine antagonists (e.g., azathioprine or 6-mercaptopurine) after resolution has been recommended as standard therapy.
  
  
  METHODS
  A 68-year-old male patient was referred to our institution in February 2012 for therapy evaluation of a steroid-dependent course of autoimmune pancreatitis type 1 with IgG4-associated cholangitis. Since the first diagnosis in March 2011, the patient was treated with high-dose steroids with good response. Whenever steroids were tapered down to a daily dose <20 mg, cholestatic liver enzymes increased dramatically despite concurrent immunosuppressive therapy primarily with azathioprine and 6-MP thereafter. Therefore, we restarted steroid therapy (1 mg/kg/day) in combination with tacrolimus achieving a target level of 5 - 7 ng/mL. During the down-tapering phase, follow-up examinations presented a patient in good general condition without jaundice. Moreover, liver and pancreatic enzymes and also immunoglobulins returned to normal values without any evidence of relapse up today (66 weeks).
  
  
  CONCLUSIONS
  In this case, the combination of steroids with tacrolimus seems to be a reasonable alternative in a patient with steroid-dependent and thiopurine-refractory autoimmune pancreatitis with IgG4-associated cholangitis. To date, this is the first description of such a therapeutic approach for this entity.
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Buechter
authors.affiliation: Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Germany.
authors.forename: C Georg
authors.initials: CG
authors.lastname: Klein
authors.affiliation: Department of Radiology, University Hospital Essen, Germany.
authors.forename: C
authors.initials: C
authors.lastname: Kloeters
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: J F
authors.initials: JF
authors.lastname: Schlaak
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Canbay
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: G
authors.initials: G
authors.lastname: Gerken
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Kahraman
mesh_terms: D000368:Aged; D001379:Azathioprine / Q000008:administration & dosage; D002761:Cholangitis / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology*; D004359:Drug Therapy, Combination / Q000379:methods; D006801:Humans; D007074:Immunoglobulin G / Q000276:immunology*; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D008297:Male; D010195:Pancreatitis / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology*; D013256:Steroids / Q000008:administration & dosage*; D016559:Tacrolimus / Q000008:administration & dosage*; D017211:Treatment Failure
chemical_list: D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; D013256:Steroids; D001379:Azathioprine; D016559:Tacrolimus