Treatment with pravastatin attenuates progression of chronic pancreatitis in rat

The Pharmacological Landscape for Fatty Change of the Pancreas

The quest for medications to reduce intra-pancreatic fat deposition is now quarter a century old. While no specific medication has been approved for the treatment of fatty change of the pancreas, drug repurposing shows promise in reducing the burden of the most common disorder of the pancreas. This leading article outlines the 12 classes of medications that have been investigated to date with a view to reducing intra-pancreatic fat deposition. Information is presented hierarchically-from preclinical studies to retrospective findings in humans to prospective interventional studies to randomised controlled trials. This lays the grounds for shepherding the most propitious drugs into medical practice through well-designed basic science studies and adequately powered randomised controlled trials.

Decreased HDL-C Levels as a Predictor of Organ Failure in Acute Pancreatitis in the Emergency Department

High-density lipoprotein cholesterol (HDL-C) is reported as a biomarker of systemic inflammation and multi-organ failure (MOF), which has been rarely investigated in acute pancreatitis (AP), a frequent condition in the emergency department (ED). The objective was to study the predictive capacity of the decrease in HDL-C to the progression of MOF in AP in the ED; analyzing 114 patients with AP for one year in a longitudinal and prospective study, AP severity was obtained by the Atlanta classification, in relation to modified Marshall and Bedside Index for Severity in Acute Pancreatitis (BISAP) scores, and clinical and laboratory parameters in a 48 h hospital stay. The area under the receiver operating characteristic (ROC) curve was used to estimate the validity of the predictor and define optimal cut-off points. It was found that AP was classified as severe in 24.5%, mainly for biliary etiology (78.9%) and female sex (73.6%). As a biomarker, HDL-C decreased from 31.6 to 29.5 mg/dL in a 48 h stay (p < 0.001), correlating negatively with the increase in severity index > 2 and the modified Marshall (p < 0.032) and BISAP (p < 0.009) scores, finding an area under the ROC curve with a predictive capacity of 0.756 (95% CI, 0.614-0.898; p < 0.004) and a cut-off point of 28.5 mg/dL (sensitivity: 79%, specificity: 78%), demonstrating that the decrease in HDL-C levels serves as a useful indicator with a predictive capacity for MOF in mild to severe AP, during a 48 h hospital stay in the ED.

Chronic use of statins and risk of post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis

BACKGROUND

There is limited evidence on the role of chronic statin therapy in the prevention of acute pancreatitis after ERCP. The aim of this meta-analysis was to evaluate the efficacy of statins in the prophylaxis of post-ERCP pancreatitis.

RESEARCH DESIGN AND METHODS

Bibliographic search was performed through May 2020. The primary outcome was post-ERCP pancreatitis rate. An additional endpoint was the rate of severe pancreatitis.

RESULTS

Nine studies, of which 1 prospective and 8 retrospective series, with 9374 patients were included. Baseline clinical and technical features were well balanced between the two study groups. Overall, pooled rate of post-ERCP pancreatitis was 4.8% (3.2%-6.4%) in the statin group and 7.1% (5.9%-8.3%) in the control group, with no difference in terms of pancreatitis rate (odds ratio 0.66, 95% confidence interval 0.43-1.02). This finding was confirmed in the multivariate analysis adjusted for several clinical and technical characteristics (adjusted odds ratio 0.68, 0.40-1.15). No difference was observed between the two study groups in terms of severe pancreatitis rate (odds ratio 1.07, 0.61-1.89).

CONCLUSIONS

Our meta-analysis seems to suggest the non-superiority of chronic statin therapy in preventing post-ERCP pancreatitis.

Regular Statin Use and Incidence of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis

GOALS AND BACKGROUND

Endoscopic retrograde cholangiopancreatography is widely utilized to diagnose and treat various pancreaticobiliary diseases, but postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) can be a fatal adverse event. Evidence suggests that statins may exhibit suppressive effects on inflammation in the pancreas. We carried out an observational cohort study to examine the protective effect of statins on PEP.

STUDY

We retrospectively identified consecutive patients who underwent endoscopic retrograde cholangiopancreatography at a tertiary care center in Japan between January 2010 and January 2019. The incidences of PEP were compared between regular and nonregular statin users. Using the multivariable logistic regression model, we examined the association of regular statin use with the incidence of PEP controlling for potential risk factors for PEP.

RESULTS

We included 2664 patients (328 regular statin users and 2336 nonregular users). The incidence of PEP did not differ by statin use status (P=0.52): 8.8% in regular statin users and 7.9% in nonregular users. The multivariable-adjusted odds ratio for PEP comparing regular statin use with nonregular use was 1.08 (95% confidence interval, 0.67-1.72; P=0.76). When we examined specific statin types (hydrophilic and lipophilic statins), we consistently observed the null association: 6.8% of 132 hydrophilic statin users and 10% of 196 lipophilic statin users (P=0.74 and 0.27, respectively, compared with nonregular users).

CONCLUSIONS

Regular statin use was not shown to be protective against PEP. A further investigation is warranted before this medication is tested in prospective randomized trials.

Statins decrease the risk of acute pancreatitis after endoscopic ultrasound fine-needle aspiration of pancreatic cysts

BACKGROUND

Basic and clinical studies suggest that statins may prevent and even ameliorate acute pancreatitis. The present study was to evaluate whether statin decreases the risk of acute pancreatitis in patients undergoing endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts.

METHODS

Out of 456 patients with pancreatic cysts referred to our center between 2006 and 2018, 365 were finally included in analyses: 86 were treated with statins and 279 were not at the time of endoscopic ultrasound fine-needle aspiration. We compared the acute pancreatitis incidence between the two groups, and we also compared other complications such as bleeding and infections.

RESULTS

Median age was 64 years [interquartile range (IQR) 62-69] and median cyst size was 24 mm (IQR, 21-29). The most frequent histology was intraductal papillary mucinous neoplasm (45.3% and 42.3% in the two groups, respectively; P = 0.98). All 13 patients experiencing post-endoscopic ultrasound acute pancreatitis were from the control group (4.7%), of which 3 were classified as severe pancreatitis. None of statin users developed post-procedural acute pancreatitis (odds ratio: 0.15; 95% confidence interval: 0.03-0.98; P = 0.03). No difference was registered with regard to severe pancreatitis and other complications.

CONCLUSIONS

Statins exert a beneficial role in preventing acute pancreatitis in patients with pancreatic cysts undergoing endoscopic ultrasound-guided fine-needle aspiration. If confirmed in prospective trials, our findings may pave the way to an extensive use of statins as prophylactic agents in pancreatic interventional endoscopy.

Chronic use of statins and risk of post-ERCP acute pancreatitis (STARK): Study protocol for an international multicenter prospective cohort study

BACKGROUND

Acute pancreatitis (AP) is the most common complication after endoscopic retrograde cholangiopancreatography (ERCP). Statins have been traditionally associated to an increased risk of AP, however, recent evidence suggests that statins may have a protective role against this disease.

AIMS

Our primary aim is to investigate whether the use of statins has a protective effect against post-ERCP pancreatitis (PEP). Secondary outcomes are: to evaluate the effect of other drugs on the incidence of PEP; to ascertain the relationship between the use of statins and the severity of PEP; and to evaluate the effect of other risk and protective factors on the incidence of PEP.

METHODS

STARK is an international multicenter prospective cohort study. Centers from Spain, Italy, Croatia, Finland and Sweden joined this study. The total sample size will include about 1016 patients, which was based on assuming a 5% incidence of PEP among non-statin (NSt) users, a 1-3 ratio of statin (St) and NSt consumers respectively, a 70% decrease in PEP among St consumers, an alpha-error of 0.05 and beta-error of 0.20. All patients aged ≥18 years scheduled for ERCP will be offered to enter the study.

DISCUSSION

STARK study will ascertain whether statins, a safe, widely used and inexpensive drug, can modify the incidence of PEP.

The relationship between the use of statins and mortality, severity, and pancreatic cancer in Danish patients with chronic pancreatitis

OBJECTIVES

Chronic pancreatitis (CP) is associated with a shortened life expectancy. Statins have anti-inflammatory properties and we aimed to evaluate the association between the use of statins and the risk of death, progression of CP, and pancreatic cancer in patients with CP.

PATIENTS AND METHODS

We carried out a nested case-cohort study and included patients with CP. We used claims of proton pump inhibitors as an active comparator. Patients with cirrhosis or cancer were excluded. We evaluated the exposure on the basis of pharmacy claims of statins. We used propensity score matching with a statins : nonstatins ratio of 1 : 1.

RESULTS

A total of 4807 patients were eligible for propensity score matching; 33% were women and the mean (SD) age at cohort entry was 56 (10) years. During follow-up, a total of 2073 (43%) patients had died and the risk of death was significantly lower among patients using statins versus no statins among 678 matched patients [hazard ratio (HR) 0.64; 95% confidence interval (CI): 0.49-0.83]. Use of statins versus no statins was associated with decreased progression of CP, with an HR of 0.21 (95% CI: 0.17-0.26). Pancreatic cancer occurred in 117 (2.4%) patients and we found a lower risk of pancreatic cancer in statin-treated patients compared with no statins, with a HR of 0.21 (95% CI: 0.06-0.70).

CONCLUSION

In this nationwide study, we found lower risks of mortality, disease progression, and pancreatic cancer in patients with CP using statins. The study is limited by its retrospective design, but supports the hypothesis that statins may affect the course of CP.

Novel and Experimental Therapies in Chronic Pancreatitis

Chronic pancreatitis (CP) is a progressive inflammatory disease of the pancreas. The currently available treatment of CP is aimed at controlling symptoms and managing complications. Unfortunately, no specific treatment is available to halt the progression of the disease process because the pathophysiological perturbations in CP are not well understood. In this review, we discuss various therapeutic targets and investigational agents acting on these targets. Among these, therapies modulating immune cells and those acting on pancreatic stellate cells appear promising and may translate into clinical benefit in near future. However, these experimental therapies are mostly in animal models and they do not recapitulate all aspects of human disease. Still they may be beneficial in developing effective therapeutic modalities to curb inflammation in chronic pancreatitis.

Pancreatic stellate cell: Pandora's box for pancreatic disease biology

Pancreatic stellate cells (PSCs) were identified in the early 1980s, but received much attention after 1998 when the methods to isolate and culture them from murine and human sources were developed. PSCs contribute to a small proportion of all pancreatic cells under physiological condition, but are essential for maintaining the normal pancreatic architecture. Quiescent PSCs are characterized by the presence of vitamin A laden lipid droplets. Upon PSC activation, these perinuclear lipid droplets disappear from the cytosol, attain a myofibroblast like phenotype and expresses the activation marker, alpha smooth muscle actin. PSCs maintain their activated phenotype via an autocrine loop involving different cytokines and contribute to progressive fibrosis in chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC). Several pathways (e.g., JAK-STAT, Smad, Wnt signaling, Hedgehog etc.), transcription factors and miRNAs have been implicated in the inflammatory and profibrogenic function of PSCs. The role of PSCs goes much beyond fibrosis/desmoplasia in PDAC. It is now shown that PSCs are involved in significant crosstalk between the pancreatic cancer cells and the cancer stroma. These interactions result in tumour progression, metastasis, tumour hypoxia, immune evasion and drug resistance. This is the rationale for therapeutic preclinical and clinical trials that have targeted PSCs and the cancer stroma.

Antidiabetic and antioxidant effects of catalpol extracted from Rehmannia glutinosa (Di Huang) on rat diabetes induced by streptozotocin and high-fat, high-sugar feed

Background

Diabetes, associated with hyperlipidemia and oxidative stress, would lead to an increased production of reactive oxygen species. Rehmannia glutinosa (Di Huang) is widely used to nourish yin, invigorate the kidney (shen), and treat xiao ke (a diabetes-like syndrome in Chinese medicine). This study aims to investigate the antidiabetic and antioxidant effects of catalpol from R. glutinosa on rat diabetes induced by streptozotocin (STZ) and high-fat, high-sugar feed.

Methods

Rats (eight rats in each group at least) were induced diabetes by an initial high-fat high-sugar feed for 3 weeks, followed by an intraperitoneal injection of STZ (30 mg/kg) for 3 days, and rats were fasted overnight before treatments. Catalpol at a dose of 0, 5, 10, 20 or 50 mg/kg was administrated through bolus intravenous injection to the experimental rats to find the most effective anti-hyperglycemic dose of catalpol to further study body weight loss, water intake, and food intake. The most effective catalpol dose was given to the diabetic model rats with hyperlipidemia, and the levels of blood sugar, plasma total cholesterol (TC), triglyceride (TG), and high-density lipoprotein cholesterol (HDL-C) were measured after catalpol administration once a day for 2 weeks. An oral glucose challenge test (OGCT) was performed after above experiments in which the most effective dose of catalpol has been determined. Levels of glutathione peroxidase (GSH-PX), catalase (CAT), superoxide dismutase (SOD), and malondialdehyde (MDA) were measured by corresponding reagent kits and morphological changes of the pancreas were observed with histopathological examination using H&E stain.

Results

Catalpol at a dose of 50 mg/kg ameliorated body weight loss and increased water and food intake. Catalpol also attenuated the increase of plasma TC (P = 0.0067) and TG (P = 0.0084) and increased HDL-C (P = 0.0336). The OGCT revealed that catalpol reduced the increase of plasma glucose. The activities of antioxidative enzymes (SOD, P = 0.0037; GSH-PX, P = 0.0066; CAT, P = 0.005) were enhanced and MDA was reduced (P = 0.003). Furthermore, catalpol reduced the morphological impairment of the pancreas.

Conclusion

Catalpol protected against STZ-induced diabetes with high-fat and high-sugar feed with ameliorated structural impairment of the pancreas and restored balance between oxidative enzymes and antioxidative enzymes.

Treatment with atorvastatin attenuates progression of insulin resistance and pancreatic fibrosis in the Otsuka Long-Evans Tokushima fatty rats

PURPOSE

The effects of statins on insulin resistance (IR) and type 2 diabetes mellitus (T2DM) are still controversial and its effects on pancreatic fibrosis are poorly defined. The purpose of this study is to examine the effects of atorvastatin on these issues using the Otsuka Long-Evans Tokushima Fatty (OLETF) rat, an animal model of IR, T2DM and pancreatic fibrosis.

METHODS

Male OLETF rats were divided into 2 groups at 6weeks of age. The first group received a standard diet until the end of experimental period at age 28weeks. The second group was given a diet containing 0.05% atorvastatin from 6weeks of age, before the onset of IR and pancreatic fibrosis. The age-matched Long-Evans Tokushima Otsuka rats without presence of IR, T2DM and pancreatic fibrosis, received a standard diet and were used as a normal control.

RESULTS

Atorvastatin slightly decreased serum fasting glucose and insulin levels, but significantly improved index of IR compared with the untreated OLETF rats. In addition, atorvastatin markedly decreased transforming growth factor-β1 mRNA expression, myeloperoxidase activity and proportion of fibrotic area, and elevated superoxide dismutase activity in the pancreas compared with the untreated OLETF rats.

CONCLUSIONS

These findings suggest that atorvastatin exerts favorable influence on progression of IR and pancreatic inflammation and fibrosis via pleiotropic effect such as anti-oxidative property.

Reappraisal of xenobiotic-induced, oxidative stress-mediated cellular injury in chronic pancreatitis: A systematic review

AIM: To reappraise the hypothesis of xenobiotic induced, cytochrome P450-mediated, micronutrient-deficient oxidative injury in chronic pancreatitis.

METHODS: Individual searches of the Medline and Embase databases were conducted for each component of the theory of oxidative-stress mediated cellular injury for the period from 1^st January 1990 to 31^st December 2012 using appropriate medical subject headings. Boolean operators were used. The individual components were drawn from a recent update on theory of oxidative stress-mediated cellular injury in chronic pancreatitis.

RESULTS: In relation to the association between exposure to volatile hydrocarbons and chronic pancreatitis the studies fail to adequately control for alcohol intake. Cytochrome P450 (CYP) induction occurs as a diffuse hepatic and extra-hepatic response to xenobiotic exposure rather than an acinar cell-specific process. GSH depletion is not consistently confirmed. There is good evidence of superoxide dismutase depletion in acute phases of injury but less to support a chronic intra-acinar depletion. Although the liver is the principal site of CYP induction there is no evidence to suggest that oxidative by-products are carried in bile and reflux into the pancreatic duct to cause injury.

CONCLUSION: Pancreatic acinar cell injury due to short-lived oxygen free radicals (generated by injury mediated by prematurely activated intra-acinar trypsin) is an important mechanism of cell damage in chronic pancreatitis. However, in contemporary paradigms of chronic pancreatitis this should be seen as one of a series of cell-injury mechanisms rather than a sole mediator.

Involvement of inflammatory factors in pancreatic carcinogenesis and preventive effects of anti-inflammatory agents

Chronic inflammation is known to be a risk for many cancers, including pancreatic cancer. Heavy alcohol drinking and cigarette smoking are major causes of pancreatitis, and epidemiological studies have shown that smoking and chronic pancreatitis are risk factors for pancreatic cancer. Meanwhile, inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) are elevated in pancreatitis and pancreatic cancer tissues in humans and in animal models. Selective inhibitors of iNOS and COX-2 suppress pancreatic cancer development in a chemical carcinogenesis model of hamsters treated with N-nitrosobis(2-oxopropyl)amine (BOP). In addition, hyperlipidemia, obesity, and type II diabetes are also suggested to be associated with chronic inflammation in the pancreas and involved in pancreatic cancer development. We have shown that a high-fat diet increased pancreatic cancer development in BOP-treated hamsters, along with aggravation of hyperlipidemia, severe fatty infiltration, and increased expression of adipokines and inflammatory factors in the pancreas. Of note, fatty pancreas has been observed in obese and/or diabetic cases in humans. Preventive effects of anti-hyperlipidemic/anti-diabetic agents on pancreatic cancer have also been shown in humans and animals. Taking this evidence into consideration, modulation of inflammatory factors by anti-inflammatory agents will provide useful data for prevention of pancreatic cancer.

Chronic pancreatitis

PURPOSE OF REVIEW

We review important new clinical observations in chronic pancreatitis reported in 2011.

RECENT FINDINGS

Smoking increases the risk of nongallstone acute pancreatitis and the progression of acute pancreatitis to chronic pancreatitis. Binge drinking during Oktoberfest did not associate with increased hospital admissions for acute pancreatitis. The unfolded protein response is an adaptive mechanism to maintain pancreatic health in response to noxious stimuli such as alcohol. Onset of diabetes mellitus in chronic pancreatitis is likely due to progressive disease rather than individual variables. Insufficient pancreatic enzyme dosing is common for treatment of pancreatic steatorrhea; 90 000 United States Pharmacopeia units of lipase should be given with meals. Surgical drainage provides sustained, superior pain relief compared with endoscopic treatment in patients advanced chronic pancreatitis with a dilated main duct ± pancreatic stones. The central acting gabapentoid pregabalin affords a modest 12% pain reduction in patients with chronic pancreatitis but approximately 30% of patients have significant side effects.

SUMMARY

Patients with nongallstone-related acute pancreatitis or chronic pancreatitis of any cause should cease smoking. Results of this year's investigations further elucidated the pancreatic pathobiology due to alcohol, onset of diabetes mellitus in chronic pancreatitis, and the mechanisms and treatment of neuropathic pain in chronic pancreatitis.