What pre‑treatment medications should be given for autoimmune pancreatitis?

Pre-Treatment Medications for Autoimmune Pancreatitis

Before initiating corticosteroid therapy for autoimmune pancreatitis, biliary drainage via ERCP should be performed in patients with obstructive jaundice, blood glucose should be controlled in those with diabetes mellitus, and perioperative antibiotics must be administered when instrumenting an obstructed bile duct to prevent cholangitis. 1, 2, 3

Biliary Drainage for Obstructive Jaundice

• Perform ERCP with biliary stenting or drainage before starting corticosteroids in patients presenting with obstructive jaundice. 1, 2, 3
• This decompression prevents cholangitis and allows safer initiation of immunosuppressive therapy. 1
• During ERCP, obtain brush cytology and/or endoscopic biopsy to definitively exclude pancreatic malignancy, as AIP can mimic pancreatic cancer with identical features including jaundice, weight loss, and pancreatic masses. 1, 2

Perioperative Antibiotic Prophylaxis

• Administer perioperative antibiotics when performing ERCP or any biliary instrumentation in patients with obstructed bile ducts to prevent cholangitis. 1, 2
• This is critical because immunosuppression with corticosteroids will be initiated shortly after the procedure, increasing infection risk. 1

Diabetes Management

• Achieve blood glucose control before starting corticosteroid therapy in patients with diabetes mellitus. 3, 4
• Corticosteroids will worsen hyperglycemia, so baseline glucose control is essential to prevent steroid-induced diabetic complications. 3
• Implement tight glucose control using sliding scale insulin if needed, as steroid therapy will be initiated at high doses (prednisolone 40 mg daily or 0.6 mg/kg/day). 2, 3

Gastric Protection

• Initiate a proton pump inhibitor (PPI) or histamine-2 receptor antagonist before starting high-dose corticosteroid therapy to prevent peptic ulcer disease. 5
• This is standard practice when initiating high-dose corticosteroids (prednisolone 40 mg daily), which carry significant GI bleeding risk. 5, 2

Bone Health Assessment

• Obtain baseline vitamin D and calcium levels and replete as needed before initiating long-term corticosteroid therapy. 5
• This is particularly important because AIP patients often require prolonged corticosteroid treatment (2-3 months of tapering plus potential maintenance therapy), increasing osteoporosis risk. 5, 2

Infection Screening

• Screen for latent tuberculosis and hepatitis B before initiating immunosuppressive therapy, particularly if azathioprine will be added as steroid-sparing maintenance. (General medical knowledge)
• This is standard practice before any prolonged immunosuppression, though not explicitly stated in AIP guidelines. (General medical knowledge)

Critical Pitfall to Avoid

• Do not delay biliary drainage in jaundiced patients while waiting for diagnostic confirmation. 1, 2
• Obstructive jaundice requires urgent decompression regardless of final diagnosis, and delaying drainage to complete diagnostic workup increases cholangitis risk and morbidity. 1