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We read with great interest the article by Masamune et al 1 regarding the role of long-term maintenance corticosteroids in patients with autoimmune pancreatitis (AIP).1 AIP is a steroid responsive disorder, which has two distinct entities with overlapping features, classified as type I and type II AIP. While type I AIP is a part of a spectrum of IgG4-related disease with extrapancreatic manifestations, type II is a pancreas-specific disease. The diagnostic criteria, treatment approach and prognosis are different between the two types. Masamune et al demonstrated that corticosteroid treatment for a prolonged period of 3 years reduces rates of relapse when compared with patients who discontinued steroid treatment at 26 weeks. The authors have showed that the two treatment groups are comparable at baseline with regard to clinical, radiological and serological characteristics. However, the authors do not reveal the distribution of the two different types of AIP (type I and II) in the two groups at baseline or among those with relapse of the disease after treatment. This is a critical factor, as the rates of relapse are significantly higher in type I as compared with type II AIP.2 Thus, it is difficult to conclusively establish that the two treatment groups were completely balanced at baseline.
The findings of Masamune et al regarding relapse rates of 23.3% (7 of 30 patients) after a 3-year steroid course differ from those of Hirano and colleagues3 who found that 10 of 21 (47.6%) patients with AIP suffered a relapse of disease after treatment with a 3-year course of steroids, with a median 43 months of follow-up. This poses questions about the ideal duration of steroid treatment in patients with AIP. At present, there is no international consensus on the steroid dosing regimen and duration of treatment for AIP. The preferred strategy in Europe and the USA is to treat with steroids, which are quickly tapered over 12 weeks. Prolonged steroid exposure can negatively affect patients in the form of worsening glycaemic control, bone loss, weight gain, infectious complications, cataracts and skin changes among others.4 The optimal duration of treatment and choice of treatment for relapse of disease (immunomodulators vs low-dose steroids) need to be evaluated in clinical trials for the development of robust clinical guidelines for management of this disease.
Contributors All authors have contributed equally to the preparation of the manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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