Drug-induced acute pancreatitis related to medications commonly used in gastroenterology

Drug-Induced Acute Pancreatitis: A Real-World Pharmacovigilance Study Using the FDA Adverse Event Reporting System Database

Timely identification and discontinuation of culprit-drug is the cornerstone of clinical management of drug-induced acute pancreatitis (AP), but the comprehensive landscape of AP culprit-drugs is still lacking. To provide the current overview of AP culprit-drugs to guide clinical practice, we reviewed the adverse event (AE) reports associated with AP in the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database from 2004 to 2022, and summarized a potential AP culprit-drug list and its corresponding AE report quantity proportion. The disproportionality analysis was used to detect adverse drug reaction (ADR) signals for each drug in the drug list, and the ADR signal distribution was integrated to show the risk characteristic of drugs according to the ADR signal detection results. In the FAERS database, a total of 62,206 AE reports were AP-related, in which 1,175 drugs were reported as culprit-drug. On the whole, metformin was the drug with the greatest number of AE reports, followed by quetiapine, liraglutide, exenatide, and sitagliptin. Drugs used in diabetes was the drug class with the greatest number of AE reports, followed by immunosuppressants, psycholeptics, drugs for acid-related disorders, and analgesics. In disproportionality analysis, 595 drugs showed potential AP risk, whereas 580 drugs did not show any positive ADR signal. According to the positive-negative distribution of the ADR signal for drug classes, the drug class with the greatest number of positive drugs was antineoplastic agents. In this study, we provided the current comprehensive landscape of AP culprit-drugs from the pharmacovigilance perspective, which can provide reference information for clinical practice.

Risk factors for drug-related acute pancreatitis: an analysis of the FDA adverse event reporting system (FAERS)

Objective: While several drugs have been linked to acute pancreatitis (AP), the AP-related risk of most drugs remains unclear. This study investigated the risk factors for drug-induced AP by analyzing a large dataset from the FDA Adverse Event Reporting System (FAERS). Methods: The reporting odds ratios (ROR) were used to assess the reports of drug-induced AP from the first quarter of 2004 to the second quarter of 2022. Single-factor, LASSO, and multi-factor regression analysis were performed to explore drug-related AP-related risk factors. Bonferroni correction was applied for the multiple comparisons performed. Results: A total of 264 drugs associated with AP, including antineoplastic drugs (35/264), antidiabetic drugs (28/264), antibacterial drugs (24/264), immunomodulatory drugs (11/264), antipsychotic drugs (6/264), and other drugs (160/264) were retrieved. Multi-factor analysis showed that males, age 41-54 years old, and 36 drugs, including Tigecycline, were risk factors for drug-related AP. The median time to drug-related AP onset was 31 days (interquartile range [IQR] 7-102 days) and about 75% of adverse events occurred within 100 days. Conclusion: These findings may help clinicians to identify drug-related AP at the early stage and can be used to inform future studies of drug-related AP pathogenesis.

Endoscopic changes in patients diagnosed with acute pancreatitis

BACKGROUND

There have been long debates on the introduction of proton pump inhibitors into acute pancreatitis therapy as standard treatment. The aim of the study was to assess endoscopic lesions of the upper gastrointestinal tract in patients hospitalized for acute pancreatitis.

METHODS

We carried out a prospective analysis of patients hospitalized in one surgical center who had an upper gastrointestinal tract endoscopic examination performed during the first 48 hours of hospitalization. We performed analysis of basic descriptive statistics along with the Shapiro-Wilk Test, logistic order regression analysis, One-Way Analysis of Variance, and Student's t-test for independent trials.

RESULTS

From January 2016 to December 2019, 476 patients were hospitalized because of acute pancreatitis. The upper gastrointestinal tract endoscopic examination was performed in 85 patients (N.) in the first 48 hours. From the examined group 45 patients (52.94%) developed mild acute pancreatitis, 28 (32.94%) moderate pancreatitis, and 12 (14.12%) severe pancreatitis. Lesions in the endoscopic imaging were observed in 80 patients (94.12%).

CONCLUSIONS

A very high percentage of patients hospitalized for acute pancreatitis present lesions in the endoscopic imaging of the upper gastrointestinal tract. The standard treatment of AP is the administration of non-steroidal anti-inflammatory drugs, which themselves can cause gastric and duodenal mucosal defects. All these factors indicate the need for standard use of proton pump inhibitors in patients hospitalized for acute pancreatitis.

Has COVID-19 Modified the Weight of Known Systemic Inflammation Indexes and the New Ones (MCVL and IIC) in the Assessment as Predictive Factors of Complications and Mortality in Acute Pancreatitis?

We aimed at evaluating the prognostic capacity of the inflammatory indices derived from routine complete blood cell counts in two groups of patients with acute pancreatitis from two different time periods, before and during the COVID-19 pandemic, when a high incidence of complications with surgical risk and mortality was found. Two new markers were introduced: the mean corpuscular volume to lymphocyte ratio (MCVL) and the cumulative inflammatory index (IIC), which were calculated at a baseline in the two groups of patients. Of the already established markers, none of them managed to effectively predict the complications with surgical risk and mortality, with a decrease of less than 50% in specificity in the peri-COVID group. The MCVL had the best prediction of complications with surgical risk in both the pre-COVID and peri-COVID groups, validated it as an independent factor by multivariate analysis. The IIC had the best prediction of mortality in both periods and was proven to be an independent factor by multivariate analysis. As the IIC predicted death best, we tested the occurrence of death and found that patients with PA who had an IIC > 12.12 presented a risk of death 4.08 times higher in the pre-COVID group and 3.33 times higher in the peri-COVID group. The new MCVL and IIC independent markers had a superior sensitivity and specificity in predicting surgical risk complications and, respectively, mortality in the group of patients with acute pancreatitis during the COVID-19 pandemic, which makes them widely applicable in populations with modified immune and inflammatory status. Conclusions: In patients with acute pancreatitis, MCVL has a significant predictive value regarding complications with surgical risk (abscess, necrosis, and pseudocyst), and the IIC has a significant predictive value for mortality.

Azathioprine-Induced Pancreatitis in a Patient With Systemic Lupus Erythematosus

Acute pancreatitis is an inflammatory disorder of the pancreas and a leading gastrointestinal cause of admission in the United States. The most common causes of acute pancreatitis are gallstones and alcohol. It is rarely caused by medications. Azathioprine-induced pancreatitis is rare and is more common in patients with Crohn's Disease. In this case report, we present a rare case of azathioprine-induced pancreatitis in a 58-year-old African American patient with systemic lupus erythematosus.

Post Kidney Transplant Cyclosporine-Induced Acute Pancreatitis

Drug-induced pancreatitis (DIP) is a rare cause of acute pancreatitis. Efforts have been made to assess the relationship between many drugs and acute pancreatitis. Also, studies have been held to investigate the possible mechanisms of DIP. Cyclosporine is one of the immunosuppressive agents that is still under investigation regarding its association with acute pancreatitis.

We report a case of a 21-year-old male patient post kidney transplant who presented with a picture of acute pancreatitis; upon further investigation, the diagnosis of cyclosporine-induced pancreatitis was made by ruling out all other possible causes of acute pancreatitis. Furthermore, he showed significant improvement and was discharged home upon stopping cyclosporine and replacing it with sirolimus, and there was no relapse of pancreatitis in three months of follow-up. 

Our case provides evidence that cyclosporine can be a possible cause of pancreatitis in post kidney transplant patients receiving cyclosporine, and how early detection of cyclosporine-induced pancreatitis can significantly improve the patient's condition.

Metabolic reprogramming of inner ear cell line HEI-OC1 after dexamethasone application

INTRODUCTION

One approach to dampen the inflammatory reactions resulting from implantation surgery of cochlear implant hearing aids is to embed dexamethasone into the matrix of the electrode carrier. Possible side effects for sensory cells in the inner ear on the metabolomics have not yet been evaluated.

OBJECTIVE

We examined changes in the metabolome of the HEI-OC1 cell line after dexamethasone incubation as a cell model of sensory cells of the inner ear.

RESULTS AND CONCLUSION

Untargeted GC-MS-profiling of metabolic alterations after dexamethasone treatment showed that dexamethasone had antithetical effects on the metabolic signature of the cells depending on growth conditions. The differentiated state of HEI-OC1 cells is better suited for elucidating metabolic changes induced by external factors. Dexamethasone treatment of differentiated cells led to an increase in intracellular amino acids and enhanced glucose uptake and β-oxidation in the cells. Increased availability of precursors for glycolysis and ATP production by β-oxidation stabilizes the energy supply in the cells, which could be assumed to be beneficial in coping with cellular stress. We found no negative effects of dexamethasone on the metabolic level, and changes may even prepare sensory cells to better overcome cellular stress following implantation surgery.

Clinical characteristics of acute pancreatitis in children: a single-center experience in Western China

BACKGROUND

The diagnosis of pediatric pancreatitis has been increasing over the last 20 years. We aimed to compare the clinical characteristics for pediatric acute pancreatitis (AP) with adult AP, and investigate the risk factor for acute recurrent pancreatitis (ARP) in children.

METHOD

From June 2013 to June 2019, a total of 130 pediatric patients with AP at the inpatient database were enrolled. Univariate analysis and multivariate Cox regression analysis were performed to identify the risk factors for ARP in children.

RESULT

Major etiologic factors in 130 patients were biliary (31.5%), idiopathic (28.5%). The etiology of pancreatitis in children was markedly different from that in adults (p < 0.001). Compared with the adult patients, the pediatric patients had significantly lower severity (p = 0.018) and occurrence rate of pancreatic necrosis (p = 0.041), SIRS (p = 0.021), acute peripancreatic fluid collection (p = 0.014). Univariate and Multivariate Cox regression analysis showed that female (p = 0.020; OR 3.821; 95% CI 1.231-11.861), hypertriglyceridemia (p = 0.045; OR 3.111; 95% CI 1.024-9.447), pancreatic necrosis (p = 0.023; OR 5.768; 95% CI 1.278-26.034) were the independent risk factors of ARP. Hypertriglyceridemia AP had the highest risk of recurrence compared to other etiology (p = 0.035).

CONCLUSION

Biliary and idiopathic disease were the major etiologies of AP in children. Children have simpler conditions than adults. Female, hypertriglyceridemia, and pancreatic necrosis were associated with the onset of ARP.

Hypertriglyceridemia-Induced Pancreatitis as a Result of Quetiapine use

Pancreatitis is caused by a number of different etiologies, most commonly caused by gallstone induced, alcohol, and familial hypertriglyceridemia. Other less common causes include trauma, medications, and autoimmune conditions. Drug-induced pancreatitis (DIP) is only responsible for less than 2% of all cases but is a very important etiology that has been observed with increasing frequency in the acute setting. Here we present a case of recurrent pancreatitis with no other risk factors except for the initiation of quetiapine approximately six months prior to the first episode. 

Drug-induced acute pancreatitis: Prevalence, Causative agents, and Outcomes

BACKGROUND

We sought to study the causative drugs, prevalence and outcomes of drug-induced acute pancreatitis (DIAP).

METHODS

Retrospective study of DIAP patients at a tertiary teaching hospital. The diagnosis and severity of pancreatitis were determined based on the Revised Atlanta Classification. The cases were further subclassified using the Badalov et al., 2008 classification, and Naranjo score to evaluate and determine the odds of drug-related adverse reaction as a causative factor for AP.

RESULTS

Out of 841 AP patients, a total of 31 patients (3.6%) with DIAP were included. The mean age was 52.9 years, 51.6% were male. The most common causative drugs are listed in Table 3. Most cases were mild in severity (87%), moderate AP occurred in 2 patients (6.5%) and severe AP in 2 patients (6.5%). 19.3% had systemic inflammatory response syndrome at presentation, but it persisted beyond 48 h in only 9.6%. 9.6% developed acute kidney injury. One patient with valproate induced DIAP had pancreatic necrosis, splenic vein thrombus, and sub occlusive superior mesenteric vein thrombus on abdominal imaging. Three patients had recurrent AP, and two (6.5%) of them eventually developed chronic pancreatitis. Notably, none of our patients developed complications such as shock, acute respiratory distress syndrome, bacteremia, or death. 1 patient had an acute peripancreatic fluid collection on initial imaging and another patient developed a pseudocyst on follow up imaging. None of them required drainage.

CONCLUSION

Our study showed a prevalence of DIAP of (3.6%) and hydrochlorothiazide, azathioprine, and doxycycline were the most common culprit drugs.

Acute pancreatitis induced by combination chemotherapy used for the treatment of acute myeloid leukemia: A case report

RATIONALE

Drug-induced pancreatitis (DIP) is a kind of acute pancreatitis with a relatively low incidence. There are many cases of acute pancreatitis (AP) caused by chemotherapeutic agents that have been reported. However, few reports focus on the combination of chemotherapeutic agents that induce acute pancreatitis. This article aims to retrospectively analyze a case of DIP and to explore the relationship between chemotherapeutic agents and acute pancreatitis.

PATIENT CONCERNS

Here, we report a 35-year-old Chinese female patient who was diagnosed as acute myeloid leukemia with BCR/ABL expression. After induction chemotherapy of daunorubicin and cytarabine, bone marrow aspiration showed: Acute myeloid leukemia-not relieved (AML-NR). Then the regimen of homoharringtonine, cytarabine and dasatinib was started. The patient developed abdominal pain on the 14th day of chemotherapy. Laboratory tests showed elevated serum amylase (AMY) and lipase (LIPA). Computed tomography (CT) of the abdomen revealed a swollen pancreas with blurred edges and thickened left prerenal fascia.

DIAGNOSIS

The patient was diagnosed as DIP by the symptoms of upper abdominal pain and the change of CT images. Other common causes of AP were excluded meanwhile.

INTERVENTIONS

The chemotherapy was stopped immediately. And after fasting, fluid infusion and inhibiting the secretion of the pancreas, the symptoms were relieved.

OUTCOMES

DIP relapsed when the regimen of aclacinomycin + cytarabine + G-CSF + dasatinib regimen (G-CSF (400ug/day, day 1 to 15), cytarabine (30 mg/day, day 2 to 15), aclacinomycin (20 mg/day, day 2 to 5)and dasatinib (140 mg/day, continuously)) was given, and was recovered after treatment for AP was performed.

LESSONS

To choose the best treatment plan for patients, clinicians should raise awareness of DIP, and should know that chemotherapeutic agents can induce pancreatitis and the combination of chemotherapeutic agents may increase the risk of drug-induced pancreatitis.

Drug-induced pancreatitis: An update

Drug-induced pancreatitis is a disease that is receiving increasing attention. This article reviews the advances in the incidence, risk factors, pathogenesis, diagnosis, treatment and prevention of drug-induced pancreatitis by reviewing the literature on drug-induced pancreatitis, especially in the literature of the latest 10 years. The incidence of drug-induced pancreatitis is relatively low, however, there is an increasing trend with the widespread use of drugs, and the incidence seems to be related to regional distribution. There is currently lack of data on the epidemiology of drug-induced pancreatitis in China. In recent years, research on the pathogenesis of drug-induced pancreatitis has made some progress, but further research is needed. Drug-induced pancreatitis is a diagnosis of exclusion. With further understanding and research, a new diagnostic approach has been proposed. Pharmacogenomics is expected to help prevent and perform an individual treatment of drug-induced pancreatitis.

Oral metronidazole use and risk of acute pancreatitis: a population-based case-control study

Objective

Oral metronidazole used in combined regimens for Helicobacter pylori eradication has been associated with an increased risk of acute pancreatitis; however, it is less clear whether a similar association exists for single-regimen metronidazole. We, therefore, examined the association of single and combined regimens of oral metronidazole with risk of acute pancreatitis.

Methods

In this population-based case-control study, all individuals in Sweden (aged 40-84 years) hospitalized with acute pancreatitis between January 2006 and December 2008 were identified from a national hospital register (n=5,996). Controls, matched for calendar year, age, and sex, were randomly sampled from a national population register (n=60,681). Data on oral metronidazole and covariates were extracted from national health and prescription registers. Odds ratios (ORs) of acute pancreatitis, according to timing of the latest metronidazole prescription before hospitalization, were estimated using logistic regression models. Confounding by indication was examined by contrasting the main results with the association when amoxicillin was used as exposure. The robustness of results was examined by calculating incidence rate ratios using a self-controlled case series approach.

Results

After adjustment for potential confounders, there was a substantially increased risk of acute pancreatitis within 30 days of oral metronidazole exposure, both for single (OR: 4.06; 95% confidence interval [CI]: 1.90-8.64) and combined (OR: 11.80; 95% CI: 6.86-20.28) regimens, compared to nonexposure. In contrast, the adjusted OR was 1.79 (95% CI: 1.25-2.54) for current use of amoxicillin compared to nonexposure. These results were supported by the self-controlled cases series analysis (incidence rate ratio: 3.30; 95% CI: 2.69-4.06, for single and combined regimens of oral metronidazole pooled). There was no strong association between oral metronidazole and acute pancreatitis more than 30 days after exposure.

Conclusion

There was an increased risk of acute pancreatitis within 30 days of exposure to single and combined regimens of oral metronidazole. While reverse causality and confounding by indication cannot be entirely excluded, they are unlikely to fully explain the association. These results warrant an increased awareness among physicians.

Amoxicillin/clavulanic acid-induced pancreatitis: case report

Background

Acute pancreatitis is an acute inflammation of the pancreas that varies in severity from mild to life threatening usually requiring hospitalization. The true incidence of drug-induced pancreatitis (DIP) is indeterminate due to the inadequate documentation of case reports of DIP. Here we present the case of amoxicillin/clavulanic acid-induced pancreatitis in a previously healthy male after excluding all other causes of pancreatitis.

Case presentation

A 58-year-old Caucasian man presenting for acute sharp abdominal pain with associated nausea and heaves. Pain was non-radiating and worsening with movement. Patient had no constitutional symptoms. The only medication he received prior to presentation was amoxicillin/clavulanic acid as prophylaxis for a dental procedure with his symptoms starting on day 9th of therapy. Laboratory studies revealed mild leukocytosis, increased levels of serum lipase, amylase, and C-reactive protein (CRP). Abdominal computed tomography (CT) was notable for acute pancreatitis with no pseudocyst formation. Hence, patient was diagnosed with mild acute pancreatitis that was treated with aggressive intravenous (IV) hydration and pain management with bowel rest of 2 days duration and significant improvement being noticed within 72 h. On further questioning, patient recalled that several years ago he had similar abdominal pain that developed after taking amoxicillin/clavulanic acid but did not seek medical attention at that time and the pain resolved within few days while abstaining from food intake. All other causes of pancreatitis were ruled out in this patient who is non-alcoholic, non-smoker, and never had gallstones. Abdominal ultrasound and magnetic resonance cholangiopancreatography (MRCP) eliminated out the possibility of gallstones, biliary ductal dilatation, or choledocholithiasis. Patient had no hypertriglyceridemia nor hypercalcemia, never had endoscopic retrograde cholangiopancreatography (ERCP), never took steroids, has no known malignancy, infection, trauma, or exposure to scorpions.

Conclusion

This case describes a patient with DIP after the intake of amoxicillin/clavulanic acid and when all other common causes of acute pancreatitis were excluded. Only two other case reports were available through literature review regarding amoxicillin/clavulanic acid- induced pancreatitis.

We again stress on the importance of identifying and reporting cases of DIP to raise awareness among physicians and clinicians.

No association between losartan use and acute pancreatitis in hypertensive patients

Background and objective

Clinical evidence is scarce about the relationship between losartan use and acute pancreatitis. We therefore conducted a population-based case-control study using the database from the Taiwan National Health Insurance Program to investigate this question.

Methods

The study consisted of 1449 hypertensive subjects aged 20-84 years with a first episode of acute pancreatitis during the period 2000-2011 as the case group and 2479 hypertensive subjects without acute pancreatitis as the control group. Both the case and control groups were matched for sex, age, comorbidities and index year of acute pancreatitis diagnosis. According to the history of losartan prescription before the date of diagnosis of acute pancreatitis, subjects who had never received a prescription for losartan were defined as 'never use of losartan', those whose last remaining losartan tablet was detected within 7 days before the date of diagnosis of acute pancreatitis were defined as 'current use of losartan' and those whose last remaining tablet of losartan was detected ≥8 days before the date of diagnosis of acute pancreatitis were defined as 'late use of losartan'. ORs and 95% CIs were measured to investigate the risk of acute pancreatitis associated with losartan use by the multivariable unconditional logistic regression model.

Results

After adjustment for potentially confounding factors, the adjusted OR of acute pancreatitis was 0.96 (95% CI 0.68 to 1.37) for subjects with current use of losartan compared with those with never use of losartan, but the difference was not statistically significant. For subjects with late use of losartan the adjusted OR of acute pancreatitis was 1.05 (95% CI 0.80 to 1.37), which also was not statistically significant.

Conclusions

No significant association can be detected between losartan use and acute pancreatitis in hypertensive patients. More research is required to determine the potential role of losartan in the risk of acute pancreatitis.

Toxic-metabolic Risk Factors in Pediatric Pancreatitis: Recommendations for Diagnosis, Management, and Future Research

Pancreatitis in children can result from metabolic and toxic risk factors, but the evidence linking these factors is sparse. We review the evidence for association or causality of these risk factors in pancreatitis, discuss management strategies, and their rationale. We conducted a review of the pediatric pancreatitis literature with respect to the following risk factors: hyperlipidemia, hypercalcemia, chronic renal failure, smoking exposure, alcohol, and medications. Areas of additional research were identified. Hypertriglyceridemia of 1000 mg/dL or greater poses an absolute risk for pancreatitis; persistent elevations of calcium are predisposing. Further research is necessary to determine whether end-stage renal disease leads to increased pancreatitis in children similar to adults. It is unknown whether cigarette smoking exposure, which clearly increases risk in adults, also increases risk in children. The role of alcohol in pediatric pancreatitis, whether direct or modifying, needs to be elucidated. The evidence supporting most cases of medication-induced pancreatitis is poor. Drug structure, improper handling of drug by host, and bystander status may be implicated. Other pancreatitis risk factors must be sought in all cases. The quality of evidence supporting causative role of various toxic and metabolic factors in pediatric pancreatitis is variable. Careful phenotyping is essential, including search for other etiologic risk factors. Directed therapy includes correction/removal of any agent identified, and general supportive measures. Further research is necessary to improve our understanding of these pancreatitis risk factors in children.

Atorvastatin Use Associated With Acute Pancreatitis: A Case-Control Study in Taiwan

Few data are present in the literature on the relationship between atorvastatin use and acute pancreatitis. The aim of this study was to explore this issue in Taiwan. Using representative claims data established from the Taiwan National Health Insurance Program, this case-control study consisted of 5810 cases aged 20 to 84 years with a first-time diagnosis of acute pancreatitis during the period 1998 to 2011and 5733 randomly selected controls without acute pancreatitis. Both cases and controls were matched by sex, age, comorbidities, and index year of diagnosing acute pancreatitis. Subjects who at least received 1 prescription for other statins or nonstatin lipid-lowering drugs were excluded from the study. If subjects never had 1 prescription for atorvastatin, they were defined as never use of atorvastatin. Current use of atorvastatin was defined as subjects whose last remaining 1 tablet of atorvastatin was noted ≤7 days before the date of diagnosing acute pancreatitis. Late use of atorvastatin was defined as subjects whose last remaining 1 tablet of atorvastatin was noted >7 days before the date of diagnosing acute pancreatitis. The odds ratio with 95% confidence interval of acute pancreatitis associated with atorvastatin use was calculated by using the logistic regression analysis. The logistic regression analysis revealed that the odds ratio of acute pancreatitis was 1.67 for subjects with current use of atorvastatin (95% confidence interval 1.18, 2.38), when compared with subjects with never use of atorvastatin. The odds ratio decreased to 1.15 for those with late use of atorvastatin (95% confidence interval 0.87, 1.52), but without statistical significance. Current use of atorvastatin is associated with the diagnosis of acute pancreatitis. Clinically, clinicians should consider the possibility of atorvastatin-associated acute pancreatitis when patients present with a diagnosis of acute pancreatitis without a definite etiology but are taking atorvastatin.

Recurrent pancreatitis after unremarkable colonoscopy, temporalised by CT imaging: an unusual case

Acute pancreatitis is a common surgical presentation, frequently caused by gallstones and alcohol. Here we present an unusual case of a recurrent episode of pancreatitis after an unremarkable colonoscopy, in a patient with several pre-existing risk factors for pancreatitis. Before and after abdominal CT scans clearly demonstrate the acute inflammatory process affecting the pancreas and temporalise its development. Early resuscitation and appropriate involvement of high dependency care is advocated by all current guidelines to improve patient outcome. We consider possible aetiology and how early diagnosis and recognition of possible high-risk situations can expedite its investigation and management, helping to provide the best possible care.

Zopiclone use associated with increased risk of acute pancreatitis: a case-control study in Taiwan

BACKGROUND

The purpose of this study was to assess the relationship between zopiclone use and the risk of acute pancreatitis in Taiwan.

METHODS

This was a population-based case-control study. The data source was from the database of the Taiwan National Health Insurance Program since 2000-2011. We identified 5169 subjects aged 20-84 years with a first-time attack of acute pancreatitis as the patients and 20,676 sex-matched and age-matched subjects without acute pancreatitis as the controls. Active use of zopiclone was defined as subjects who received at least one prescription for zopiclone within 30 days before the date of diagnosing acute pancreatitis. The lack of zopiclone prescription was defined as 'never use'. We calculated the odds ratio (OR) and 95% confidence interval (CI) to assess the risk of acute pancreatitis associated with zopiclone use by the multivariable logistic regression model.

RESULTS

After adjustment for potential confounding variables, the adjusted OR of acute pancreatitis was 2.36 for subjects with active use of zopiclone (95% CI 1.70-3.28), as compared with those with never use of zopiclone. In further analysis, as a reference of subjects with never use of zopiclone and without alcohol-related disease and biliary stone, the adjusted OR increased to 14.44 in those with active use of zopiclone and with alcohol-related disease or biliary stone (95% CI 7.47-27.89).

CONCLUSIONS

Subjects actively using zopiclone are associated with increased risk of acute pancreatitis. Clinicians should take acute pancreatitis risk into account when prescribing zopiclone, particularly comorbid with alcohol-related disease or biliary stone.

A case of survival after chlorfenapyr intoxication with acute pancreatitis

Chlorfenapyr is a moderately hazardous insecticide. There have been previous reports of chlorfenapyr intoxication, but none have reported patient survival or an association with pancreatitis. A 61-year-old woman was brought to the emergency department with vomiting after ingesting 10 mL chlorfenapyr in a suicide attempt 1 hour before. The patient was treated with gastric lavage and activated charcoal, then transferred to the intensive care unit. Initial laboratory data were unremarkable except for elevated amylase/lipase levels (134/222 U/L), which were even higher 7 days later and remained elevated for 2 weeks. Abdominal computed tomography showed diffuse pancreatic swelling. The patient improved with conservative care and was discharged to home 19 days after admission. This is the first reported case of survival after chlorfenapyr intoxication. We recommend early aggressive management in the emergency department and close monitoring in the intensive care unit to detect and treat potentially fatal deterioration after chlorfenapyr intoxication.

Finasteride use and acute pancreatitis in Taiwan

The aim of this study was to examine whether there is an association between finasteride use and the risk of acute pancreatitis. This population-based case-control study used the database of the Taiwan National Health Insurance Program. There were 2,530 male subjects aged 40-84 years with a first-attack of acute pancreatitis during the period of 1998-2011 as the case group and 10,119 randomly selected subjects without acute pancreatitis as the control group. Both groups were matched by age and index year of diagnosing acute pancreatitis. Subjects who never had finasteride prescription were defined as "never use." Subjects who at least received 1 prescription for finasteride before the date of diagnosing acute pancreatitis were defined as "ever use." The association of acute pancreatitis with finasteride use was examined by the odds ratio (OR) and 95% confidence interval (CI) using the multivariable unconditional logistic regression model. The crude OR of acute pancreatitis was 1.78 (95%CI 1.33, 2.39) for subjects with ever use of finasteride, when compared with subjects with never use of finasteride. After adjusting for potential confounders, the adjusted OR of acute pancreatitis decreased to 1.25 (95%CI 0.90, 1.73) for subjects with ever use of finasteride, but no statistical significance was seen. No association can be detected between finasteride use and the risk of acute pancreatitis.

Digoxin use may increase the relative risk of acute pancreatitis: A population-based case-control study in Taiwan

OBJECTIVES

The goal of this study was to evaluate the association between digoxin use and acute pancreatitis in Taiwan.

METHODS

Utilizing the database of the Taiwan National Health Insurance Program, this case-control study consisted of 6116 subjects aged 20-84years with a first-attack of acute pancreatitis since 2000 to 2011 as the cases and 24,464 randomly selected subjects without acute pancreatitis as the controls. Both cases and controls were matched by sex, age and index year of diagnosing acute pancreatitis. The absence of digoxin prescription was defined as "never use". Active use of digoxin was defined as subjects who at least received 1 prescription for digoxin within 7days before the date of diagnosing acute pancreatitis. Non-active use of digoxin was defined as subjects who did not receive a prescription within 7days but at least received 1 prescription for digoxin ≥8days before the date of diagnosing acute pancreatitis. The odds ratio (OR) and 95% confidence interval (CI) were measured to evaluate the association between digoxin use and acute pancreatitis by a multivariable unconditional logistic regression model.

RESULTS

After adjusting for potential confounding factors, the adjusted OR of acute pancreatitis was 5.29 for subjects with active use of digoxin (95% CI 3.61, 7.73), when compared with subjects with never use of digoxin. The adjusted OR of acute pancreatitis decreased to 1.04 for subjects with non-active use of digoxin (95% CI 0.89, 1.21), but no statistical significance.

CONCLUSIONS

These data indicate that only persons actively using digoxin may have the high relative odds of acute pancreatitis. Further research or case report is warranted to evaluate the pathophysiological basis underlying the relationship between digoxin use and acute pancreatitis.

High fat diet and GLP-1 drugs induce pancreatic injury in mice

Glucagon Like Peptide-1 (GLP-1) drugs are currently used to treat type-2 diabetes. Safety concerns for increased risk of pancreatitis and pancreatic ductal metaplasia have accompanied these drugs. High fat diet (HFD) is a type-2 diabetes risk factor that may affect the response to GLP-1 drug treatment. The objective of the present study was to investigate the effects of diet and GLP-1 based drugs on the exocrine pancreas in mice. Experiments were designed in a mouse model of insulin resistance created by feeding a HFD or standard diet (STD) for 6weeks. The GLP-1 drugs, sitagliptin (SIT) and exenatide (EXE) were administered once daily for additional 6weeks in both mice fed HFD or STD. The results showed that body weight, blood glucose levels, and serum levels of pro-inflammatory cytokines (TNFα, IL-1β, and KC) were significantly greater in HFD mice than in STD mice regardless of GLP-1 drug treatment. The semi-quantitative grading showed that pancreatic changes were significantly greater in EXE and SIT-treated mice compared to control and that HFD exacerbated spontaneous exocrine pancreatic changes seen in saline-treated mice on a standard diet. Exocrine pancreatic changes identified in this study included acinar cell injury (hypertrophy, autophagy, apoptosis, necrosis, and atrophy), vascular injury, interstitial edema and inflammation, fat necrosis, and duct changes. These findings support HFD as a risk factor to increased susceptibility/severity for acute pancreatitis and indicate that GLP-1 drugs cause pancreatic injury that can be exacerbated in a HFD environment.

Metformin induced acute pancreatitis

Acute pancreatitis frequently presents with abdomen pain but may presents with various skin manifestations as rash and rarely, pancreatic panniculitis. Metformin, one of the most effective and valuable oral hypoglycemic agents in the biguanide class was linked to acute pancreatitis in few cases. Here, we report a case of metformin induce acute pancreatitis in young healthy man with normal renal function.

Clinical challenges in drug induced pancreatitis: Presentation of two cases and review of the literature

INTRODUCTION

A wide variety of drugs have been reported to cause pancreatitis. Although the incidence of drug induced acute pancreatitis is low, the disease is associated with substantial morbidity and mortality, which makes timely identification of the causative agent important.

PRESENTATION OF CASE

Herein, we report two patients with clinical, biochemical, and radiological evidence of acute pancreatitis. There were no etiologic factors except their prescribed drugs.

DISCUSSION

The majority of patients with acute pancreatitis recover uneventfully, but there remains an uncontrollable risk of mortality. It is prudent to withdraw a medication with a known association with acute pancreatitis. Necessity of multi-drug regimens especially in oncological patients however, presents a challenge.

CONCLUSION

Corticosteroid pulse therapy was easily detectable as the causative agent in our first case, but combined anti-neoplastic drug therapy and additional multi-drug regimen presented great difficulties in identifying single causative agent in our second patient.