Pancréatite aiguë liée au glimépiride (Amarel®)

Incidence and precipitants of hospitalization for pancreatitis in people with diabetes: the Fremantle Diabetes Study

AIMS

To determine the relative risk of pancreatitis in diabetes, and to establish whether diabetes-related as well as recognized risk factors contribute.

METHODS

We studied 1426 participants [mean (SD) age 62.1 (13.3) years, 49.6% male, 90.9% type 2 diabetes, median (interquartile range) diabetes duration 4.0 (1.0-10.0) years] from the community-based Fremantle Diabetes Study Phase I and 5663 matched residents without diabetes from the same geographical area. Pancreatitis hospitalizations between 1982 and 2010 were ascertained using validated data linkage. For Fremantle Diabetes Study Phase I participants, chart review provided data on the likely causes of pancreatitis.

RESULTS

A total of 21 Fremantle Diabetes Study Phase I participants (1.5%) were hospitalized for pancreatitis before study entry vs 29 (0.5%) of contemporaneous residents without diabetes. During a mean (SD) of 12.1 (5.4) years of follow-up from entry, 22 (1.6%) Fremantle Diabetes Study Phase I participants were hospitalized for a first-ever episode of pancreatitis on 37 occasions (1.31/1000 person-years) compared with 58 (1.0%) residents without diabetes on 81 occasions during a mean (SD) 13.6 (4.8) years (0.75/1000 person-years). The age- and sex-adjusted hazard ratio (95% CI) for first-ever pancreatitis hospitalization in Fremantle Diabetes Study Phase I participants was 1.73 (1.06-2.83; P=0.029). Chart review of 17 of the 22 Fremantle Diabetes Study Phase I participants (77%) with incident pancreatitis and available case notes revealed that four (24%) presented without objective evidence of pancreatitis, seven (41%) presented with cholelithiasis, three (18%) with excessive alcohol consumption, two (12%) as a complication of elective endoscopic retrograde cholangiopancreatography, and one (6%) with hypertriglyceridaemia.

CONCLUSION

Consistent with previously published data, the risk of pancreatitis was higher in community-dwelling Fremantle Diabetes Study Phase I participants but conventional precipitants accounted for confirmed cases. These data question whether diabetes-specific risk factors cause or contribute to pancreatitis.

Sitagliptin: review of preclinical and clinical data regarding incidence of pancreatitis

Recent case reports of acute pancreatitis in patients with type 2 diabetes (T2DM) treated with incretin-based therapies have triggered interest regarding the possibility of a mechanism-based association between pancreatitis and glucagon-like peptide-1 mimetics or dipeptidyl peptidase-4 (DPP-4) inhibitors. The objective of this review was to describe the controlled preclinical and clinical trial data regarding the incidence of pancreatitis with sitagliptin, the first DPP-4 inhibitor approved for use in patients with T2DM. Tissue samples from multiple animal species treated with sitagliptin for up to 2 years at plasma exposures substantially in excess of human exposure were evaluated to determine whether any potential gross or histomorphological changes suggestive of pancreatitis occurred. Sections were prepared by routine methods, stained with haematoxylin and eosin and examined microscopically. A pooled analysis of 19 controlled clinical trials, comprising 10,246 patients with T2DM treated for up to 2 years, was performed using patient-level data from each study for the evaluation of clinical and laboratory adverse events. Adverse events were encoded using the Medical Dictionary for Regulatory Activities (MedDRA) version 12.0 system. Incidences of adverse events were adjusted for patient exposure. Tissue samples from preclinical studies in multiple animal species did not reveal any evidence of treatment-related pancreatitis. The pooled analysis of controlled clinical trials revealed similar incidence rates of pancreatitis in patients treated with sitagliptin compared with those not treated with sitagliptin (0.08 events per 100 patient-years vs. 0.10 events per 100 patient-years, respectively). Preclinical and clinical trial data with sitagliptin to date do not indicate an increased risk of pancreatitis in patients with T2DM treated with sitagliptin.

Exenatide-induced acute pancreatitis

OBJECTIVE

To report acute pancreatitis in a patient with non-insulin-dependent diabetes mellitus (NIDDM) receiving exenatide and critically review previous reports.

METHODS

We describe clinical and laboratory data of a woman with probable exenatide-induced pancreatitis and apply the same criteria to previously published cases.

RESULTS

A 64-year-old, nonalcoholic woman with NIDDM presented with a 1-month history of epigastric pain beginning 2 days after starting exenatide. Serum lipase concentration was 2700 U/L (reference range, 114-320 U/L), and serum amylase concentration was 131 U/L (reference range, 30-110 U/L). Liver function test results, lipid profile, and serum creatinine concentration were normal. Abdominal computed tomography (CT) showed changes consistent with pancreatitis, and the gallbladder was absent. Exenatide was discontinued. Conservative therapy resulted in rapid resolution of symptoms, normal lipase concentration (151 U/L), and normal findings from CT of the pancreas 90 days later. The US Food and Drug Administration has reported 36 cases of presumed pancreatitis associated with exenatide. However, none of the selection criteria were specified, two-thirds of the patients did not have CT, and 90% had at least 1 other risk factor for acute pancreatitis. A single published case report of exenatide-induced pancreatitis contains no description of the pancreas on abdominal CT, does not mention alcohol use, and does not report normal lipase values.

CONCLUSIONS

This is the most thoroughly documented example of probable exenatide-induced pancreatitis. In any diabetic patient with acute pancreatitis, exenatide must be ruled out as the cause and its use discontinued.

Sitagliptin: review of preclinical and clinical data regarding incidence of pancreatitis

Recent case reports of acute pancreatitis in patients with type 2 diabetes (T2DM) treated with incretin-based therapies have triggered interest regarding the possibility of a mechanism-based association between pancreatitis and glucagon-like peptide-1 mimetics or dipeptidyl peptidase-4 (DPP-4) inhibitors. The objective of this review was to describe the controlled preclinical and clinical trial data regarding the incidence of pancreatitis with sitagliptin, the first DPP-4 inhibitor approved for use in patients with T2DM. Tissue samples from multiple animal species treated with sitagliptin for up to 2 years at plasma exposures substantially in excess of human exposure were evaluated to determine whether any potential gross or histomorphological changes suggestive of pancreatitis occurred. Sections were prepared by routine methods, stained with haematoxylin and eosin and examined microscopically. A pooled analysis of 19 controlled clinical trials, comprising 10,246 patients with T2DM treated for up to 2 years, was performed using patient-level data from each study for the evaluation of clinical and laboratory adverse events. Adverse events were encoded using the Medical Dictionary for Regulatory Activities (MedDRA) version 12.0 system. Incidences of adverse events were adjusted for patient exposure. Tissue samples from preclinical studies in multiple animal species did not reveal any evidence of treatment-related pancreatitis. The pooled analysis of controlled clinical trials revealed similar incidence rates of pancreatitis in patients treated with sitagliptin compared with those not treated with sitagliptin (0.08 events per 100 patient-years vs. 0.10 events per 100 patient-years, respectively). Preclinical and clinical trial data with sitagliptin to date do not indicate an increased risk of pancreatitis in patients with T2DM treated with sitagliptin.