Drug-induced pancreatitis: an update

Paediatric pancreatitis

PURPOSE OF REVIEW

The purpose of this review is to describe recent developments in paediatric pancreatitis and to discuss causes and current management.

RECENT FINDINGS

Although recent studies have estimated the annual incidence of paediatric acute pancreatitis approaching that of adults, there are no established guidelines about its diagnosis and treatment in children. Genetic and structural/congenital abnormalities are emerging as the primary risk factors for paediatric acute recurrent and chronic pancreatitis. Specifically, chronic pancreatitis is associated with a significant socioeconomic burden in children. Both medical and surgical therapies are proposed for paediatric chronic pancreatitis, but there is little evidence that they are beneficial.

SUMMARY

Acute recurrent and chronic pancreatitis create significant health issues in the paediatric population. Medical and surgical therapies exist to potentially treat these conditions, but the paediatric data are limited and the cohorts are small. A multidisciplinary and multicentre approach is necessary to better determine pancreatic disease processes and treatment options in children.

PANCREATITIS OR NOT?--Elevated lipase and amylase in ICU patients

Elevation in serum levels of pancreatic enzymes (Hyperamylasemia and/or Hyperlipasemia) can occur in any Intensive Care Unit (ICU) patient either as a result of true acute pancreatitis (AP) or as a reflection of a non-pancreatic disease. Although most patients may not have clinical pancreatitis, identifying true acute pancreatitis in the ICU setting may be critical in the presence of associated co-morbid conditions of the disease for which the patient is being managed. With neither amylase nor lipase being specific for pancreatitis, it is important for the clinician to be aware of different causes of hyperamylasemia and hyperlipasemia, especially when clinical diagnosis of pancreatitis is unclear. This review will focus on understanding different non-pancreatic conditions where there is elevation of pancreatitis enzymes and to identify true acute pancreatitis in critically ill patients without typical symptoms.

Acute Pancreatitis Induced by Methimazole in a Patient With Subclinical Hyperthyroidism

We report here a unique case of methimazole (MMI)-induced pancreatitis. To our knowledge, this is the sixth case reported in the literature and the first diagnosed in a patient with toxic multinodular goiter. A 51-year-old Caucasian female with a history of benign multinodular goiter and subclinical hyperthyroidism was started on MMI 10 mg orally daily. Three weeks later, she developed sharp epigastric pain, diarrhea, lack of appetite, and fever. Her lipase was elevated 5 times the upper limit of normal, consistent with acute pancreatitis. There was no history of hypertriglyceridemia, or alcohol abuse. Abdominal computed tomography was consistent with acute uncomplicated pancreatitis, without evidence of gallstones or tumors. MMI was discontinued, and her hyperthyroid symptoms were managed with propranolol. Her acute episode of pancreatitis quickly resolved clinically and biochemically. One year later, she redeveloped mild clinical symptoms of hyperthyroidism with biochemical evidence of subclinical hyperthyroidism. MMI 10 mg orally daily was restarted. Five days later, she experienced progressive abdominal discomfort. Her lipase was elevated 12 times the upper limit of normal, and the abdominal computed tomography was again compatible with acute uncomplicated pancreatitis. MMI was again discontinued, which was followed by rapid resolution of her pancreatitis. The patient is currently considering undergoing definitive therapy with radioactive iodine ablation. Our case as well as previous case reports in the literature should raise awareness about the possibility of pancreatitis in subjects treated with MMI in the presence of suggestive symptoms. If the diagnosis is confirmed by elevated pancreatic enzymes, the drug should be discontinued.

Possible Sulfamethoxazole/Trimethoprim-Induced Pancreatitis in a Complicated Adolescent Patient Posttraumatic Injury

Introduction:

Multiple medications have been associated with pancreatitis, however, data in the pediatric population are scarce secondary to the nonspecific presentation and infrequent diagnosis. The aim of this report is to characterize drug-induced pancreatitis in an adolescent patient.

Case Presentation:

A 16-year-old African-American female presented with a surgical site infection 8 weeks after a motor vehicle accident with multiple traumas. Two weeks prior to the admission, the patient was hospitalized for a urinary tract infection (UTI) and was initiated on sulfamethoxazole/trimethoprim (TMP/SMX) daily for UTI prophylaxis. On day 13, the patient was diagnosed with acute pancreatitis with an amylase level of 187 units/L (normal = 30-110) and a lipase level of 987 units/L (normal = 23-208). TMP/SMX was discontinued, and pancreatic enzyme levels decreased but did not reach normal. The patient was asymptomatic at discharge.

Discussion:

TMP/SMX was identified as the likely etiology of pancreatitis by the medical team. Evaluation with the Naranjo algorithm indicated a “possible” adverse drug reaction.

Conclusion:

Acute pancreatitis can have significant morbidity and mortality in the pediatric population but can go undiagnosed due to its lower incidence. Pediatric patients presenting with idiopathic abdominal pain should be evaluated for pancreatitis and drug therapy should be reviewed for potential causative agents.

Increased relative risk of acute pancreatitis in zolpidem users

OBJECTIVES

The aim of this study was to investigate the relationship between zolpidem use and the risk of acute pancreatitis in Taiwan.

METHODS

In this population-based case-control study using the database from the Taiwan National Health Insurance Program from 2000 to 2011, we selected 4535 subjects aged 20-84 years with the first episode of acute pancreatitis as cases and 18,140 subjects without acute pancreatitis matched for sex, age, and index year as controls. Immediate use of zolpidem was defined as subjects who received at least one prescription for zolpidem within 7 days before the date of diagnosing acute pancreatitis. The absence of zolpidem prescription was defined as never use. The odds ratio (OR) and 95 % confidence interval (CI) were used to evaluate the risk of acute pancreatitis associated with zolpidem use and other comorbidities.

RESULTS

After adjustment for confounding factors, the multivariable logistic regression model demonstrated that the adjusted OR of acute pancreatitis was 7.20 for immediate use of zolpidem (95 % CI 5.81, 8.92), when compared to those with never use of zolpidem. In further analysis, as a reference of subjects with never use of zolpidem and without any of these comorbidities including alcoholism, biliary stone, diabetes mellitus, hepatitis B, hepatitis C, and hypertriglyceridemia, the adjusted OR was 18.04 in those with immediate use of zolpidem and without any comorbidity (95 % CI 12.71, 25.60). The OR increased to 30.32 in subjects with immediate use of zolpidem and with any comorbidity (95 % CI 23.71, 38.79).

CONCLUSIONS

Patients actively using zolpidem are at 7-fold increased odds of acute pancreatitis. Clinicians should be more cautious of acute pancreatitis risk among patients with any comorbidity studied when prescribing zolpidem.

Incretin-based drugs and risk of acute pancreatitis: A nested-case control study within a healthcare database

To assess the association between use of incretin-based drugs for diabetes mellitus and the occurrence of acute pancreatitis. A population-based, nested case-control study was performed within a cohort of 166,591 patients from the Lombardy region (Italy) aged 40 years or older who were newly treated with oral antihyperglycaemic agents between 2004 and 2007. Cases were 666 patients who experienced acute pancreatitis from April 1, 2008 until December 31, 2012. For each case patient, up to 20 controls were randomly selected from the cohort and matched on gender, age at cohort entry, and date of index prescription. Conditional logistic regression was used to model the risk of acute pancreatitis associated with use of incretin-based drugs within 30 days before hospitalization, after adjustment for several risk factors, including the use of other antihyperglycaemic agents. Sensitivity analyses were performed in order to account for possible sources of systematic uncertainty. Use of incretin-based drugs within 30 days was reported by 17 (2.6%) cases of acute pancreatitis versus 193 (1.5%) controls. The corresponding multivariate odds ratio was 1.75 (95% confidence interval, 1.02 to 2.99). Slightly lower and no significant excess risks were observed by shortening (15 days) and increasing (60 and 90 days) the time-window at risk. This study supports a possible increased risk of acute pancreatitis in relation to use of incretin-based drugs reported in a few previous studies. However, given the potential for bias and the inconsistency with other studies, additional investigations are needed to clarify the safety of incretin-based-drugs.

Rosuvastatin and risk of acute pancreatitis in a population-based case-control study

BACKGROUND/OBJECTIVES

Few data exist about the relationship between rosuvastatin use and acute pancreatitis. We tested a plausible hypothesis that rosuvastatin use might be associated with acute pancreatitis in Taiwan.

METHODS

We designed a case-control study using a randomly sampled database of the Taiwan National Health Insurance Program. We identified 5728 subjects with the first episode of acute pancreatitis in 1998-2011 as the case group and we randomly selected 22,912 sex- and age-matched subjects without acute pancreatitis as the control group. Subjects who never received a rosuvastatin prescription were defined as never use of rosuvastatin. Subjects who at least received 1 prescription for rosuvastatin within 7 days before the date of diagnosing acute pancreatitis were defined as active use of rosuvastatin. Subjects who did not receive a prescription within 7 days but at least received 1 prescription for rosuvastatin ≥ 8 days before the date of diagnosing acute pancreatitis were defined as non-active use of rosuvastatin. Those at least receiving 1 prescription for other statins or non-statin lipid-lowering drugs were excluded from this study. We estimated the odds ratio with 95% confidence interval for acute pancreatitis associated with rosuvastatin use by using the multivariable unconditional logistic regression model.

RESULTS

The multivariable analysis disclosed that the adjusted odds ratio for acute pancreatitis in subjects with active use of rosuvastatin was 3.21 (95% confidence interval 1.70, 6.06). The adjusted odds ratio was 0.90 in subjects with non-active use of rosuvastatin (95% confidence interval 0.67, 1.19), without statistical significance.

CONCLUSIONS

We observed active use of rosuvastatin to be associated with increased risk for acute pancreatitis.

A Rare and Unexpected Side-Effect of Cannabis Use: Abdominal Pain due to Acute Pancreatitis

Acute pancreatitis is a frequently encountered disorder in patients presenting to emergency units. Biliary system disorders, alcohol consumption, infections, and drugs are among the causes of acute pancreatitis. However, it is sometimes difficult to determine the etiology of this disorder, particularly if the patient does not wish to disclose his consumption of cannabis, the use of which is illegal.

Acute pancreatitis secondary to ciprofloxacin therapy in patients with infectious colitis

BACKGROUND/AIMS

Ciprofloxacin is considered to be a safe and effective treatment for acute infectious colitis. However, this drug may cause drug-induced pancreatitis, albeit rarely.

METHODS

From March 2007 to February 2012, we studied 227 patients who were hospitalized for infectious colitis at St. Mary's Hospital. All of the patients received ciprofloxacin therapy for the treatment of infectious colitis. We observed a few cases of rare adverse events, including ciprofloxacin-induced acute pancreatitis diagnosed based on the Naranjo algorithm.

RESULTS

During ciprofloxacin therapy, seven of 227 patients (3.1%) developed rare pancreatitis as defined by the Naranjo algorithm; pancreatic enzyme activity was sporadically elevated with ciprofloxacin use. After ciprofloxacin administration, the average interval until the development of pancreatitis was 5.5 days (range, 4 to 7 days). On abdominal computed tomography, pancreatic swelling and homogenous enhancement was noted in three of seven patients. Complicating acute pancreatitis was gradually but completely resolved after cessation of ciprofloxacin administration. The mean recovery time was 11.3 days (range, 8 to 15 days).

CONCLUSIONS

We observed that ciprofloxacin-induced pancreatitis may occur with an incidence of approximately 3%. Ciprofloxacin-induced pancreatitis presents a short latency, suggesting an idiosyncratic hypersensitivity reaction. Practitioners should be aware that drug-induced pancreatitis can occur during ciprofloxacin therapy.

Bortezomib-induced acute pancreatitis: Case report and review of the literature

Acute pancreatitis is a rare complication of chemotherapy agents. We describe the case of a patient with multiple myeloma who developed acute pancreatitis after treatment with bortezomib, a proteasome inhibitor commonly used in the treatment of this disease. We reviewed the available medical literature on this topic, and found other seven similar cases, all after intravenous bortezomib. Our case is the first one occurring with the subcutaneous route of administration.

Antiretroviral drugs and acute pancreatitis in HIV/AIDS patients: is there any association? A literature review

In HIV-seropositive individuals, the incidence of acute pancreatitis may achieve 40% per year, higher than the 2% found in the general population. Since 1996, when combined antiretroviral therapy, known as HAART (highly active antiretroviral therapy), was introduced, a broad spectrum of harmful factors to the pancreas, such as opportunistic infections and drugs used for chemoprophylaxis, dropped considerably. Nucleotide analogues and metabolic abnormalities, hepatic steatosis and lactic acidosis have emerged as new conditions that can affect the pancreas. To evaluate the role of antiretroviral drugs to treat HIV/AIDS in a scenario of high incidence of acute pancreatitis in this population, a systematic review was performed, including original articles, case reports and case series studies, whose targets were HIV-seropositive patients that developed acute pancreatitis after exposure to any antiretroviral drugs. This association was confirmed after exclusion of other possible etiologies and/or a recurrent episode of acute pancreatitis after re-exposure to the suspected drug. Zidovudine, efavirenz, and protease inhibitors are thought to lead to acute pancreatitis secondary to hyperlipidemia. Nucleotide reverse transcriptase inhibitors, despite being powerful inhibitors of viral replication, induce a wide spectrum of side effects, including myelotoxicity and acute pancreatitis. Didanosine, zalcitabine and stavudine have been reported as causes of acute and chronic pancreatitis. They pose a high risk with cumulative doses. Didanosine with hydroxyurea, alcohol or pentamidine are additional risk factors, leading to lethal pancreatitis, which is not a frequent event. In addition, other drugs used for prophylaxis of AIDS-related opportunistic diseases, such as sulfamethoxazole-trimethoprim and pentamidine, can produce necrotizing pancreatitis. Despite comorbidities that can lead to pancreatic involvement in the HIV/AIDS population, antiretroviral drug-induced pancreatitis should always be considered in the diagnosis of patients with abdominal pain and elevated pancreatic enzymes.

A systematic review of acute pancreatitis as an adverse event of type 2 diabetes drugs: from hard facts to a balanced position

The question whether antidiabetes drugs can cause acute pancreatitis dates back to the 1970s. Recently, old concerns have re-emerged following claims that use of incretins, a new class of drugs for type 2 diabetes, might increase the relative risk of acute pancreatitis up to 30-fold. Given that diabetes is per se a potent risk factor for acute pancreatitis and that drug-related acute pancreatitis is rare and difficult to diagnose, we searched the medical databases for information linking acute pancreatitis and type 2 diabetes drugs. Among the biguanides, both phenformin and metformin (the latter in patients with renal insufficiency) have been cited in case reports as a potential cause of acute pancreatitis. Sulphonylureas, as both entire class and single compound (glibenclamide), have also been found in cohort studies to increase its risk. No direct link was found between pancreatic damage and therapy with metaglinide, acarbose, pramlintide or SGLT-2 inhibitors. In animal models, thiazolinediones have demonstrated proprieties to attenuate pancreatic damage, opening perspectives for their use in treating acute pancreatitis in humans. Several case reports and the US Food and Drug Administration pharmacovigilance database indicate an association between acute pancreatitis and incretins, dipeptidyl peptidase-4 (DPP-4) inhibitors, and GLP-1 receptor agonists. To date, however, a clear-cut odds ratio for this association has been reported in only one of eight pharmacoepidemiological studies. Finally, none of the intervention trials investigating these compounds, including two large randomized controlled trials with cardiovascular endpoints, confirmed the purportedly increased risk of acute pancreatitis with incretin use.

Analysis of metabolic characteristics in a rat model of chronic pancreatitis using high-resolution magic-angle spinning nuclear magnetic resonance spectroscopy

Pathological and metabolic alterations co-exist and co-develop in the progression of chronic pancreatitis (CP). The aim of the present study was to investigate the metabolic characteristics and disease severity of a rat model of CP in order to determine associations in the observed pathology and the metabolites of CP using high-resolution magic-angle spinning nuclear magnetic resonance spectroscopy (HR-MAS NMR). Wistar rats (n=36) were randomly assigned into 6 groups (n=6 per group). CP was established by administering dibutyltin dichloride solution into the tail vein. After 0, 7, 14, 21, 28 and 35 days, the pancreatic tissues were collected for pathological scoring or for HR-MAS NMR. Correlation analyses between the major pathological scores and the integral areas of the major metabolites were determined. The most representative metabolites, aspartate, betaine and fatty acids, were identified as possessing the greatest discriminatory significance. The Spearman’s rank correlation coefficients between the pathology and metabolites of the pancreatic tissues were as follows: Betaine and fibrosis, 0.454 (P=0.044); betaine and inflammatory cell infiltration, 0.716 (P=0.0001); aspartate and fibrosis, −0.768 (P=0.0001); aspartate and inflammatory cell infiltration, −0.394 (P=0.085); fatty acid and fibrosis, −0.764 (P=0.0001); and fatty acid and inflammatory cell infiltration, −0.619 (P=0.004). The metabolite betaine positively correlated with fibrosis and inflammatory cell infiltration in CP. In addition, aspartate negatively correlated with fibrosis, but exhibited no significant correlation with inflammatory cell infiltration. Furthermore, the presence of fatty acids negatively correlated with fibrosis and inflammatory cell infiltration in CP. HR-MAS NMR may be used to analyze metabolic characteristics in a rat model of different degrees of chronic pancreatitis.

Acute pancreatitis induced by methimazole treatment in a 51-year-old korean man: a case report

Methimazole (MMI)-induced acute pancreatitis is very rare but severe adverse reaction. A 51-yr-old male developed a high fever, chills, and abdominal pain, two weeks after commencement on MMI for the treatment of Graves' disease. There was no evidence of agranulocytosis, and fever subsided soon after stopping MMI treatment. However, 5 hr after taking an additional dose of MMI, abdominal pain and fever developed again. His symptoms, biochemical, and imaging studies were compatible with acute pancreatitis. After withdrawal of MMI, he showed clinical improvement. This is the first case of MMI-induced acute pancreatitis in Korea. Clinicians should be aware of the rare but possible MMI-induced pancreatitis in patients complaining of fever and abdominal pain.

Evaluation of miR-216a and miR-217 as potential biomarkers of acute pancreatic injury in rats and mice

Mild injury of the exocrine pancreas is often asymptomatic and can be under- or mis-diagnosed. The pancreas-enriched microRNAs miR-216a and miR-217 were evaluated as potential serum biomarkers of exocrine pancreas injury in rodent models of acute pancreatitis induced by caerulein, l-arginine, and pancreatic duct ligation. Both microRNAs showed time- and dose- relevant responses to pancreatic injury and wider dynamic ranges of response than serum amylase or lipase. Pancreas-selective microRNAs were found to be relatively sensitive serum biomarkers of pancreatic injury in rodents with potentially greater specificity than the current standard assays.

Acute pancreatitis during pregnancy: a review

This article aims to draw together recent thinking on pregnancy and acute pancreatitis (AP), with a particular emphasis on pregnancy complications, birth outcomes and management of AP during pregnancy contingent on the etiology. AP during pregnancy is a rare but severe disease with a high maternal-fetal mortality, which has recently decreased thanks to earlier diagnosis and some maternal and neonatal intensive care improvement. AP usually occurs during the third trimester or the early postpartum period. The most common causes of AP are gallstones (65 to 100%), alcohol abuse and hypertriglyceridemia. Although the diagnostic criteria for AP are not specific for pregnant patients, Ranson and Balthazar criteria are used to evaluate the severity and treat AP during pregnancy. The fetal risks from AP during pregnancy are threatened preterm labor, prematurity and in utero fetal death. In cases of acute biliary pancreatitis during pregnancy, a consensual strategy could be adopted according to the gestational age, and taking in consideration the high risk of recurrence of AP (70%) with conservative treatment and the specific risks of each treatment. This could include: conservative treatment in first trimester and laparoscopic cholecystectomy in second trimester. During the third trimester, conservative treatment or endoscopic retrograde cholangiopancreatography with biliary endoscopic sphincterotomy, and laparoscopic cholecystectomy in early postpartum period are recommended. A multidisciplinary approach, including gastroenterologists and obstetricians, seems to be the key in making the best choice for the management of AP during pregnancy.

Triggering ubiquitination of IFNAR1 protects tissues from inflammatory injury

Type 1 interferons (IFN) protect the host against viruses by engaging a cognate receptor (consisting of IFNAR1/IFNAR2 chains) and inducing downstream signaling and gene expression. However, inflammatory stimuli can trigger IFNAR1 ubiquitination and downregulation thereby attenuating IFN effects in vitro. The significance of this paradoxical regulation is unknown. Presented here results demonstrate that inability to stimulate IFNAR1 ubiquitination in the Ifnar1(SA) knock-in mice renders them highly susceptible to numerous inflammatory syndromes including acute and chronic pancreatitis, and autoimmune and toxic hepatitis. Ifnar1(SA) mice (or their bone marrow-receiving wild type animals) display persistent immune infiltration of inflamed tissues, extensive damage and gravely inadequate tissue regeneration. Pharmacologic stimulation of IFNAR1 ubiquitination is protective against from toxic hepatitis and fulminant generalized inflammation in wild type but not Ifnar1(SA) mice. These results suggest that endogenous mechanisms that trigger IFNAR1 ubiquitination for limiting the inflammation-induced tissue damage can be purposely mimicked for therapeutic benefits.

Postmenopausal hormone replacement therapy and risk of acute pancreatitis: a prospective cohort study

BACKGROUND

Several case reports have suggested that women's use of exogenous sex hormones is associated with acute pancreatitis; however, relevant epidemiologic data are sparse. We examined the association between postmenopausal hormone replacement therapy and risk of acute pancreatitis.

METHODS

We conducted a prospective study involving 31,494 postmenopausal women (aged 48-83 yr) from the population-based Swedish Mammography Cohort. Participants completed a baseline questionnaire in 1997 assessing their use of hormone replacement therapy. We linked the cohort to the hospital-based Swedish National Patient Register to determine hospital admissions for acute pancreatitis through 2010. Relative risks (RRs) were calculated using Cox proportional hazard models.

RESULTS

Over a total follow-up of 389,456 person-years, we identified 237 cases of incident acute pancreatitis. The age-standardized incidence rates per 100,000 person-years were 71 cases among women who had ever used hormone replacement therapy and 52 cases among women who had never used such hormones. Among ever users of hormone replacement therapy, the multivariable-adjusted RR of acute pancreatitis was 1.57 (95% confidence interval [CI] 1.20-2.05) compared with never users. The risk did not differ by current or past use, but it seemed to be higher among women who used systemic therapy (RR 1.92, 95% CI 1.38-2.66) and among those with duration of therapy of more than 10 years (RR 1.87, 95% CI 1.11-3.17).

INTERPRETATION

Use of postmenopausal hormone replacement therapy was associated with increased risk of acute pancreatitis. Physicians should consider this potential increase in risk when prescribing such therapy.

A pooled analysis of exenatide use and risk of acute pancreatitis

OBJECTIVE

To estimate the association between exenatide BID use and acute pancreatitis across two claims-based studies.

RESEARCH DESIGN AND METHODS

We pooled two cohort studies within separate commercial health insurance databases. We included initiators of exenatide BID and all other antihyperglycemic drugs without prior pancreatitis from 2005-2008. Poisson regression models provided rate ratios (RRs) and 95% confidence intervals (CIs) of the association of exenatide BID with acute pancreatitis adjusted for quintiles of propensity scores.

MAIN OUTCOME MEASURES

Primary inpatient diagnoses of acute pancreatitis with correction for misclassification via a validation sub-study.

RESULTS

There were 49,956 initiators of exenatide BID and 692,333 initiators of other antihyperglycemic drugs. Patients in the two studies were similar on many demographic and clinical characteristics. Exenatide BID initiators had a higher prevalence of diagnoses consistent with diabetes complications (e.g. peripheral neuropathy) and cardiovascular risk factors (e.g. hypertension). In both studies, current exenatide BID use was not associated with uncorrected outcomes of acute pancreatitis (pooled RR 1.0; CI 0.8-1.3). PPV correction resulted in a slightly higher point estimate for current use (pooled RR 1.3; CI 1.0-1.7) and past use (pooled RR 1.6; 95% CI 1.2-2.1).

CONCLUSIONS

These data are consistent with little or no higher risk of acute pancreatitis associated with current exenatide BID use relative to nonuse. Although previous work identified non-causal mechanisms, an increased incidence of acute pancreatitis following cessation of treatment remains a possibility. Bias due to residual confounding or outcome misclassification may remain, and should be considered a potential explanation for these findings.

Overview of exocrine pancreatic pathobiology

Exocrine pancreas is a source of several enzymes that are essential for the digestive process. The exocrine pancreatic secretion is tightly regulated by the neuroendocrine system. The endocrine pancreas is tightly integrated anatomically and physiologically with the exocrine pancreas and modulates its function. Compound-induced pancreatitis is not a common event in toxicology or drug development, but it becomes a significant liability when encountered. Understanding the species-specific differences in physiology is essential to understand the underlying pathobiology of pancreatic disease in animal models and its relevance to human disease. This review will mainly focus on understanding the morphology and physiology of the pancreas, unique islet-exocrine interactions, and pancreatitis.

Drug-induced acute pancreatitis: results from the hospital-based Berlin case-control surveillance study of 102 cases

BACKGROUND

Drug toxicity is a well-known cause of acute pancreatitis (AP). Although many drugs have been associated with AP, the magnitude of the risk of most of them remains largely unknown.

AIM

To determine the pancreatotoxic risk of a wide range of drugs.

METHODS

The hospital-based Berlin case-control surveillance study, including all 51 Berlin hospitals in a hospital network, ascertained 102 cases with idiopathic AP (IAP) and 750 controls between 2002 and 2011. Patients with IAP were thoroughly validated using anamnestic, clinical or laboratory data. Drug exposure was obtained in a face-to-face interview. Possible drug aetiology was assessed in individual patients through a standardised causality assessment applying the criteria of the World Health Organization. Drug risks were further quantified [odds ratios (OR) with 95% confidence intervals (CI)] in a case-control design with unconditional logistic regression analysis.

RESULTS

The pancreatotoxic risk of several drugs, including azathioprine (OR 5.1; 95% CI 1.9-13.5), fenofibrate (OR 12.2; 95% CI 2.3-69.1), mesalazine (OR 3.3; 95% CI 1.1-9.5) or angiotensin-converting enzyme inhibitors, was corroborated by case-control analysis and causality assessment. Causality assessment suggested a pancreatotoxic potential, among others, for mercaptopurine or the seldom reported leflunomide, and alluded to a novel risk for tocilizumab. Case-control analysis showed an increased risk for two phytotherapeutics: harpagophytum and valerian radix.

CONCLUSIONS

Our study quantified the pancreatotoxic risk of different drugs and phytotherapeutics. The findings corroborate previous results from the literature but also indicate risks for substances not previously reported, highlighting the need for further controlled studies on pancreatic toxicity.

Eluxadoline benefits patients with irritable bowel syndrome with diarrhea in a phase 2 study

BACKGROUND & AIMS

Simultaneous agonism of the μ-opioid receptor and antagonism of the δ-opioid receptor can reduce abdominal pain and diarrhea in patients with irritable bowel syndrome with diarrhea (IBS-D) without constipating side effects. We evaluated the efficacy and safety of a minimally absorbed, μ-opioid receptor agonist and δ-opioid receptor antagonist (eluxadoline) in a phase 2 study in patients with IBS-D.

METHODS

We randomly assigned 807 patients to groups that received oral placebo twice daily or 5, 25, 100, or 200 mg oral eluxadoline for 12 weeks. The primary end point was clinical response at week 4, defined by a mean reduction in daily pain score from baseline of ≥ 30%, and of at least 2 points on 0-10 scale, as well as a stool consistency score of 3 or 4 on the Bristol Stool Scale (1-7) for at least 66% of daily diary entries during that week.

RESULTS

Significantly more patients receiving 25 mg (12.0%) or 200 mg (13.8%) eluxadoline met the primary end point of clinical response than patients given placebo (5.7%; P < .05). Patients receiving eluxadoline at 100 mg and 200 mg also had greater improvements in bowel movement frequency and urgency, global symptoms, quality of life, and adequate relief assessments (P < .05). Additionally, patients receiving 100 mg (28.0%) or 200 mg (28.5%) eluxadoline were significantly more likely than those receiving placebo (13.8%; P < .005) to meet the US Food and Drug Administration response end point during the full 12 weeks of the study. Eluxadoline was well tolerated with a low incidence of constipation.

CONCLUSIONS

In a phase 2 study of the mixed μ-opioid receptor agonist/δ-opioid receptor antagonist eluxadoline vs placebo in patients with IBS-D, patients given eluxadoline were significantly more likely to be clinical responders, based on a composite of improvement in abdominal pain and stool consistency. Further study of eluxadoline is warranted to assess its potential as a treatment for IBS-D.

Autophagy in pancreatic acinar cells in caerulein-treated mice: immunolocalization of related proteins and their potential as markers of pancreatitis

Drug-induced pancreatitis (DIP) is an underdiagnosed condition that lacks sensitive and specific biomarkers. To better understand the mechanisms of DIP and to identify potential tissue biomarkers, we studied experimental pancreatitis induced in male C57BL/6 mice by intraperitoneal injection of caerulein (10 or 50 μg/kg) at 1-hr intervals for a total of 7 injections. Pancreata from caerulein-treated mice exhibited consistent acinar cell autophagy and apoptosis with infrequent necrosis. Kinetic assays for serum amylase and lipase also showed a dose-dependent increase. Terminal deoxynucleotidyl transferase-mediated biotin-dNTP nick labeling (TUNEL) detected dose-dependent acinar cell apoptosis. By light microscopy, autophagy was characterized by the formation of autophagosomes and autolysosomes (ALs) within the cytoplasm of acinar cells. Immunohistochemical studies with specific antibodies for proteins related to autophagy and pancreatic stress were conducted to evaluate these proteins as potential biomarkers of pancreatitis. Western blots were used to confirm immunohistochemical results using pancreatic lysates from control and treated animals. Autophagy was identified as a contributing process in caerulein-induced pancreatitis and proteins previously associated with autophagy were upregulated following caerulein treatment. Autophagosomes and ALs were found to be a common pathway, in which cathepsins, lysosome-associated membrane protein 2, vacuole membrane protein 1, microtubule-associated protein 1 light chain 3 (LC3), autophagy-related protein 9, Beclin1, and pancreatitis-associated proteins were simultaneously involved in response to caerulein stimulus. Regenerating islet-derived 3 gamma (Reg3γ), a pancreatic acute response protein, was dose-dependently induced in caerulein-treated mice and colocalized with the autophagosomal marker, LC3. This finding supports Reg3γ as a candidate biomarker for pancreatic injury.

[Acute pancreatitis induced by valproic acid]

INTRODUCTION

We describe the case of an adult man aged 49, without personal antecedents, or family psychiatric history, treated for bipolar disorder since 1995 and stabilised in the last 8 years by valproic acid, who presented in January 2010 an acute drug-induced pancreatitis. Drug-induced pancreatitis has been described since 1955. It may be induced by more than 260 various molecules, as well as by valproic acid, which remains underreported in the literature because there is a problem of imputability.

BACKGROUND

The prevalence of acute drug-induced pancreatitis is set between 1 and 2 %. However, it must remain as an exclusion diagnosis after conducting an exhaustive etiological investigation that will, notably, eliminate bilary and alcoholic causes. The most incriminated drugs are the inhibitors of the conversion enzyme, sulfa drugs, non-steroidal anti-inflammatory, diuretics and anticonvulsants, including valproic acid. In Tunisia, the prescription of valproic acid is increasing in bipolar disorder therapy because it is known for its weak toxicity and easy handling.

CASE REPORT

The case of our patient, who suffers from an acute Balthazar stage C pancreatitis with severe evolution after the drug was stopped, the imputability of valproic acid was considered strong and the collegial decision between the surgery, pharmacovigilance and psychiatry services maintained the drug-induced origin and consequently stopped the valproic acid.

DISCUSSION

This case supports the idea that acute pancreatitis may be induced by valproic acid, even after a prescription lasting for a long period of time, it has no predictable factors and is totally independent of the drug-related dose and of depakine blood levels. There are no predictive factors to the present day, but the evolution is generally good except in rare cases where it may be dangerous. This leads us to think of bipolar patients who are found within weak grounds, such as alcoholics, cancer and HIV positive patients.

Methadone, codeine and acute haemorrhagic necrotising pancreatitis: which came first?

Acute haemorrhagic necrotising pancreatitis lead to the death at home of a young female who was on a methadone maintenance programme. Toxic levels of codeine with potentially lethal levels of methadone and morphine were found at post-mortem. Whether opiates caused the pancreatitis or were the consequence of self-medication for pain is impossible to differentiate. Forensic toxicology may pose the question but be unable to provide the answer.

Tigecycline-Induced Acute Pancreatitis with Rechallenge: A Case Report

Objective:

To report a case of tigecycline-induced acute pancreatitis.

Case Summary:

A 50-year-old African American man with spinal cord injury was hospitalized on 2 occasions for recurrence of an infected pressure ulcer requiring systemic antibiotic therapy. Bone and tissue cultures from his initial hospitalization grew multidrug resistant (MDR) Acinetobacter baumanii sensitive to tigecycline. He was treated with intravenous tigecycline on these 2 occasions (50-mg infusions every 12 hours), each of which resulted in significant elevation in serum amylase (to 615 U/L and 715 U/L) and lipase (to 325 U/L and 616 U/L) levels. On each occasion, the pancreatic enzymes became normal after discontinuing tigecycline.

Discussion:

Tigecycline is the first FDA-approved drug in the class of antibiotics called glycylcyclines, which are developed from tetracyclines to afford broad coverage against certain resistant gram-positive and gramnegative bacteria. It is recommended for patients at least 18 years of age for treatment of complicated intraabdominal infections, community-acquired bacterial pneumonia and complicated skin and skin structure infections caused by susceptible organisms. Tigecycline-induced pancreatitis is a rare adverse event. Review of the literature yielded only 6 prior documented cases (5 adult and 1 pediatric cases). Although the pediatric case demonstrated rechallenge, the patient concurrently received other antibiotics that are known to cause pancreatitis.

Conclusions:

This is the first report, to our knowledge, of pancreatitis associated with monotherapy with tigecycline, and this relationship was confirmed upon rechallenging our patient with tigecycline. An objective causality assessment revealed that the adverse-drug-associated event was definite.

A review of the efficacy and safety of oral antidiabetic drugs

INTRODUCTION

Additional oral antidiabetic agents to metformin, sulfonylureas (SU) and thiazolidinediones (TZD) are approved for the treatment of type 2 diabetes.

AREAS COVERED

The efficacy and safety of metformin, SUs, TZDs, dipeptidyl peptidase-IV (DPP-4) inhibitors, meglitinide analogs, α-glucosidase inhibitors (AGIs), bile-acid sequestrants (BAS) and bromocriptine will be reviewed.

EXPERT OPINION

Several new oral agents have been approved for type 2 diabetes management in recent years. It is important to understand the efficacy and safety of these medications in addition to the older agents to best maximize oral drug therapy for diabetes. Of the recently introduced oral hypoglycemic/antihyperglycemic agents, the DPP-4 inhibitors are moderately efficacious compared with mainstay treatment with metformin with a low side-effect profile and have good efficacy in combination with other oral agents and insulin. They are a recommended alternative when metformin use is limited by gastrointestinal (GI) side effects or when SU treatment results in significant hypoglycemia or weight gain. Meglitinide analogs are limited by their frequent dosing, expense and hypoglycemia (repaglinide > nateglinide), while AGIs are also limited by their dosing schedule and GI side-effect profile. BAS and bromocriptine have the lowest efficacy with regard to HbA(1c) reduction, also are plagued by GI adverse reactions, but have a low risk of hypoglycemia.

Gadolinium induced recurrent acute pancreatitis

Acute pancreatitis is a sudden swelling and inflammation of the pancreas. The two most common causes are alcohol use and biliary stones. Drug-induced acute pancreatitis are rare (1.4-2%). In this present study, we present a case of recurrent acute pancreatitis induced by a specific magnetic-resonance-imaging (MRI) contrast agent called gadobenate dimeglumine.

Acute Pancreatitis Induced by Azathioprine and 6-mercaptopurine Proven by Single and Low Dose Challenge Testing in a Child with Crohn Disease

We report here a case of drug-induced acute pancreatitis proved by elimination and single, low dose challenge test in a child with Crohn disease. A 14-year-old boy with moderate/severe Crohn disease was admitted due to high fever and severe epigastric pain during administration of mesalazine and azathioprine. Blood test and abdominal ultrasonography revealed acute pancreatitis. After discontinuance of the medication and supportive care, the symptoms and laboratory findings improved. A single, low dose challenge test was done to confirm the relationship of the adverse drug reaction and acute pancreatitis, and to discriminate the responsible drug. Azathioprine and 6-mercaptopurine showed positive responses, and mesalazine showed a negative response. We introduce the method of single, low dose challenge test and its interpretation for drug-induced pancreatitis.

The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis)

Chronic pancreatitis (CP) is a relatively uncommon, complex and heterogeneous disease. The absence of a gold standard applicable to the initial phases of CP makes its early diagnosis difficult. Some of its complications, particularly chronic pain, can be difficult to manage. There is much variability in the diagnosis and treatment of CP and its complications amongst centers and professionals. The Spanish Pancreatic Club has developed a consensus on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. A list of questions was drafted, and two experts reviewed each question. Then, a draft was produced and shared with the entire panel of experts and discussed in a face-to-face meeting. This first part of the consensus addresses the diagnosis of CP and its complications.

Drug-induced pancreatitis

Drugs are thought to be a rare cause for acute pancreatitis; however 525 different drugs are listed in the World Health Organization (WHO) database suspected to cause acute pancreatitis as a side effect. Many of them are widely used to treat highly prevalent diseases. The true incidence is not entirely clear since only few systematic population based studies exist. The majority of the available data are derived from case reports or case control studies. Furthermore, the causality for many of these drugs remains elusive and for only 31 of these 525 dugs a definite causality was established. Definite proof for causality is defined by the WHO classification if symptoms reoccur upon rechallenge.In the actual algorithm the diagnosis is confirmed if no other cause of acute pancreatitis can be detected, and the patient is taking one of the suspected drugs.

Acute pancreatitis induced by methimazole therapy

Among the causative factors for acute pancreatitis, adverse drug reactions are considered to be rare. The diagnosis of drug-induced pancreatitis (DIP) is challenging to establish, and is often underestimated because of the difficulties in determining the causative agent and the need for a retrospective re-evaluation of the suspected agent. We present the case of an 80-year-old woman who presented with complaints of abdominal pain. Her medications included methimazole (MMI) which she had been on for the past 3 months. Computed tomography of her abdomen showed peripancreatic fat stranding with trace amount of surrounding fluid, along with amylase and lipase levels suggestive of acute pancreatitis. In the absence of classical risk factors for acute pancreatitis, a diagnosis of DIP secondary to MMI use was made. Withdrawal of the drug from her medication regimen was accompanied by relief of symptoms and resolution of clinical evidence of pancreatitis. The aim of this paper is to report only the fourth case of MMI-induced pancreatitis in the published literature, and to illustrate the significance of an appropriate and timely diagnosis of DIP.

Recurrent acute pancreatitis probably induced by rosuvastatin therapy: a case report

Context. Approximately 1.4–2% of all cases of acute pancreatitis are drug related in general population. The literature on statin-induced pancreatitis consists primarily of anecdotal case reports. We report a case of possible rosuvastatin-induced pancreatitis. Case Report. A 67-year-old female presented with progressively worsening abdominal pain and vomiting for 7 days. Home medications included rosuvastatin and clonidine. CT scan of abdomen, with intravenous contrast, showed findings consistent with acute pancreatitis. She responded to conservative management. Rosuvastatin was resumed at the time of discharge from the hospital, and she presented two months later with recurrence of acute pancreatitis. Further workup ruled out all likely causes of acute pancreatitis. Rosuvastatin was stopped completely when she was discharged the second time, and she did not have any further episodes of acute pancreatitis. She was completely asymptomatic throughout the 18-month follow-up period. Conclusion. This paper reinforces the possible association of rosuvastatin, a novel statin, with acute pancreatitis, even though the exact underlying mechanism of statin-induced pancreatitis remains unknown.

Pancreatic pseudocysts: prognostic factors for their development and their spontaneous resolution in the setting of acute pancreatitis

BACKGROUND AND AIM

Previous studies on the development of pancreatic pseudocysts following acute pancreatitis were monocentric, mostly retrospective, did not fulfil the Atlanta criteria, and featured a mixture of patients with post-acute and chronic pancreatitis. Therefore, the natural course of pancreatic pseudocysts after acute pancreatitis and the reasons for their spontaneous resolution remain unknown.

METHODS

This prospective study of 369 patients investigated the prognostic factors for development of pancreatic pseudocysts and for their spontaneous resolution after a first episode of acute pancreatitis.

RESULTS

On discharge, 124 (34%) patients still had pancreatic fluid collections. The prognostic factor for these fluid collections was severe acute pancreatitis. Follow-up examination 3 and 6 months later showed pancreatic pseudocysts in 36 (10%) patients (30 with and 6 without prior fluid collection), and in 27 (7%) patients (25 with and 2 without pancreatic pseudocyst after 3 months), respectively. The prognostic factors for their development were alcohol abuse and an initial severe course of the disease. Spontaneous complete resolution of the pancreatic pseudocysts occurred in 11 (31%) of the 36 patients. Prognostic factors for the spontaneous resolution were no or mild symptoms (nausea, vomiting, abdominal pain) and a maximal cyst diameter of <4 cm.

CONCLUSIONS

Patients with a first severe attack of acute pancreatitis and fluid collections at discharge should be checked by ultrasonography for pancreatic pseudocysts 3 months later. In patients with a small pseudocyst and mild symptoms therapy may be postponed for a further 3 months, since spontaneous resolution is possible.

Acute pancreatitis and concomitant use of pancreatitis-associated drugs

OBJECTIVES

Drug-induced pancreatitis (DIP) is considered a relative rare disease entity, perhaps due to lack of recognition. The objective of this study was to evaluate the prevalence of pancreatitis-associated drugs in a Dutch cohort of patients admitted for acute pancreatitis (AP) and to identify the proportion AP possibly attributable to the use of drugs.

METHODS

This was a multicenter observational study (EARL study). Etiology, disease course, use of pancreatitis-associated drugs at hospital admittance, and discontinuation of these drugs were evaluated. Drugs were scored by means of an evidence-based DIP classification system.

RESULTS

The first documented hospital admissions of 168 patients were analyzed. In all, 70 out of 168 (41.6%; 95% confidence interval (CI): 34.5-49.2%) patients used pancreatitis-associated drugs at admission. In 26.2% (44/168; 95% CI: 20.1-33.3%) of cases, at least one class I pancreatitis-associated drug was used. Possibly DIP was present in 12.5% (21/168; 95% CI: 8.3-18.4%); in less than half of these patients (9/21 or 42.9%; 95% CI: 24.5-63.5%), the prescribed drugs were actually discontinued, with no recurrence of AP later on. Among the remaining 12 patients without discontinuation of their drugs use and in absence of an alternative etiologic cause of AP, 8 patients used a class I pancreatitis-associated drug, representing 4.8% (8/168, 95% CI: 2.4-9.1%) of the total study population.

CONCLUSIONS

In this series, a remarkably high percentage of patients who were admitted because of an attack of AP used pancreatitis-associated drugs. Physicians should be more aware of the possibility of DIP in patients with otherwise unexplained AP and act appropriately by discontinuation of the drug.