Review article: drug-induced pancreatitis

Drug-Induced Acute Pancreatitis: An Evidence-Based Classification (Revised)

INTRODUCTION

Drug induced acute pancreatitis is a difficult diagnosis for clinicians. We previously published an "Evidence-Based Classification System" on Drug-Induced Acute Pancreatitis widely used by clinicians to assist in the identification of drugs. Unfortunately, this prior analysis based only on published case reports has been misunderstood. The prior review did not include studies with higher evidentiary value, such as randomized trials, case-control studies, and/or pharmacoepidemiologic studies. The use of the prior classification system has led to many patients being inappropriately labeled as having drug-induced acute pancreatitis. We now propose a "Revised" Evidence- Based Classification System for the purpose of determining which drugs cause acute pancreatitis based on the Grading of Recommendations, Development, and Evaluation criteria.

METHODS

A search of the English Language literature was performed to identify all case reports with medication and/or drug induced acute pancreatitis. We divided the drugs implicated as causing acute pancreatitis into four groups based on the quality of evidence as defined by GRADE quality parameters.

RESULTS

Although 141 drugs were identified in the literature as causing acute pancreatitis, only 106 drugs published in the literature as causing acute pancreatitis were high quality case reports. Only 3 drugs had evidence as causing acute pancreatitis from randomized controlled clinical trials, including 6-mercaptopurine and azathioprine.

DISCUSSION

The vast majority of drugs implicated as causing acute pancreatitis in the literature have low or very low quality of evidence supporting those claims.

Severe, Complicated Pancreatitis With an Unclear Etiology

Acute pancreatitis is an inflammatory process. There can be many causes of pancreatitis, which include alcohol or gallstones but can also be due to hypercalcemia, infections, or hypertriglyceridemia. Most cases of pancreatitis are mild and without complications. Severe cases of pancreatitis can cause complications, including organ failure. Pseudocysts are a rare complication of pancreatitis and may require management. We present a patient with severe acute pancreatitis with organ failure admitted to the intensive care unit, stabilized, and required subsequent management of a pseudocyst with cystogastrostomy with a lumen-apposing metal stent. The patient subsequently improved and is doing well today. Herein, we present an acute severe pancreatitis case report with an extensive workup complicated by pseudocyst development. We review pancreatitis causes, including rare causes and management.

Drug-Induced Acute Pancreatitis in Hospitalized COVID-19 Patients

Coronavirus disease-19 (COVID-19), caused by SARS-CoV-2, is a systemic disease that affects not only the respiratory system, but also other systems, including gastrointestinal. A great number of different drugs have been used on hospitalized patients for the management of COVID-19, and acute pancreatitis (AP) has been reported as a complication or side effect of these drugs. The development of drug-induced acute pancreatitis (DIAP) follows a complex of pathophysiological mechanisms, and particular risk factors play a key role. Diagnosis of DIAP depends on specific criteria, and based on these, a drug may be characterized as having a definite, probable or possible connection with AP. The aim of this review is to present the medications that are used for COVID-19 management and are associated with AP in hospitalized patients. The list of these drugs mainly includes corticosteroids, glucocorticoids, non-steroidal anti-inflammatory drugs (NSAIDs), antiviral agents, antibiotics, monoclonal antibodies, estrogens and anesthetic agents. Moreover, the prevention of the development of DIAP is vital, especially for critically ill patients who may receive multiple drugs. DIAP management is mainly non-invasive and the first step concerns the exception of the suspicious drug from patients therapy.

Drug-Induced Acute Pancreatitis in Hospitalized COVID-19 Patients

Coronavirus disease-19 (COVID-19), caused by SARS-CoV-2, is a systemic disease that affects not only the respiratory system, but also other systems, including gastrointestinal. A great number of different drugs have been used on hospitalized patients for the management of COVID-19, and acute pancreatitis (AP) has been reported as a complication or side effect of these drugs. The development of drug-induced acute pancreatitis (DIAP) follows a complex of pathophysiological mechanisms, and particular risk factors play a key role. Diagnosis of DIAP depends on specific criteria, and based on these, a drug may be characterized as having a definite, probable or possible connection with AP. The aim of this review is to present the medications that are used for COVID-19 management and are associated with AP in hospitalized patients. The list of these drugs mainly includes corticosteroids, glucocorticoids, non-steroidal anti-inflammatory drugs (NSAIDs), antiviral agents, antibiotics, monoclonal antibodies, estrogens and anesthetic agents. Moreover, the prevention of the development of DIAP is vital, especially for critically ill patients who may receive multiple drugs. DIAP management is mainly non-invasive and the first step concerns the exception of the suspicious drug from patients therapy.

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.

A case of methimazole-induced acute pancreatitis with an HLA allele causing antithyroid drug-induced agranulocytosis

Among the side effects of methimazole (MMI) for the treatment of Graves’ disease, MMI-induced acute pancreatitis (MIP) is a rare adverse reaction, with only 7 cases being reported to date. However, 2 large-scale population-based studies recently revealed that the risk of MIP was significantly higher, ranging from 0.02% to 0.56%. Although MIP is common in middle-aged and elderly Asian women, its pathogenesis remains largely unknown. We herein present a case of a 72-year-old Japanese woman with Graves’ disease who developed MIP 12 days after the initiation of MMI. The MMI was discontinued, the patient was switched to propylthiouracil (PTU) therapy, and pancreatitis gradually resolved. Serological human leukocyte antigen (HLA) typing identified HLA-DRB1*08:03:02. This HLA allele was previously detected in a patient with MIP and is one of the major risk factors for agranulocytosis induced by antithyroid drugs, including PTU as well as MMI. In cases of MIP, PTU is being considered as an alternative to MMI; however, its safety needs further investigation and patients require close monitoring after the switch to PTU. Further studies are warranted, particularly on the relationship between MIP and the presence of HLA alleles causing antithyroid drug-induced agranulocytosis.

A case report of tigecycline induced acute pancreatitis in a renal transplant patient and review of the literature: Should we avoid tigecycline in patients on calcineurin inhibitors?

Tigecycline has been approved by the US (United States) Food and Drug Administration in a variety of complicated infections due to its broad-spectrum antibiotic activity. Following phase III trials, the product label was revised and acute pancreatitis was listed as an adverse effect. Its safety profile in special groups such as renal transplant patients is not exactly known. We report the first case of unintentional rechallenge of tigecycline induced pancreatitis in a renal transplant patient. Ten days following the renal transplantation, a 35-year-old patient presented to the clinic with acute rejection. He received anti-thymocyte globulin (ATG) and pulse steroid treatments for rejection. Following the treatment, he developed perianal cellulitis and tigecycline was started. Nine days following initiation of tigecycline he received thrombectomy for his incidental cardiac thrombus. One day after thrombectomy, he developed acute pancreatitis (AP). Thrombectomy was suspected to be the cause of AP. During hospitalization for transplant rejection, tigecycline was re-started for a newly developed complicated abdominal infection. On the third day of the tigecycline re-treatment, he developed a second episode of AP. Following tigecycline withdrawal, his symptoms resolved and serum pancreatic enzymes returned to normal, thus AP was ultimately attributed to tigecycline. This lethal side effect should be kept in mind while treating severe infections in renal transplant recipients.

A Rare Case Report of Herbal Medication Induced Pancreatitis

Acute pancreatitis is an acute inflammation of the pancreas that varies in clinical manifestation from mild to life-threatening that may require hospitalization. A 56-year-old male patient with a past medical history of diabetes mellitus and osteoarthritis developed acute pancreatitis likely secondary to the use of herbal medication intended for weight loss. Other causes of pancreatitis were excluded. This report describes a case of herbal medication-associated pancreatitis after the exclusion of other causes. The incidence of herbal medication-associated pancreatitis is indeterminate due to inadequate literature on similar cases. The aim of this review is to describe the effect of herbal-based medicines and their counteraction on developing acute pancreatitis.

The Incidence of Propofol-Induced Hypertriglyceridemia and Identification of Associated Risk Factors

Supplemental Digital Content is available in the text.

Objectives:

The objective of this study was to describe the incidence of propofol-induced hypertriglyceridemia and the risk factors associated with hypertriglyceridemia in mechanically ventilated ICU patients while receiving propofol.

Design:

This was a single-center case-control study.

Setting:

Brigham and Women’s Hospital, a tertiary academic medical center in Boston, MA.

Subjects:

Adult ICU patients who received continuous infusion propofol for at least 24 hours from May 1, 2019, to December 31, 2019, were included. Patients were excluded if they were diagnosed with acute pancreatitis upon admission or did not have any serum triglyceride levels evaluated during propofol administration.

Interventions:

None.

Measurements and Main Results:

The major outcome was the incidence and risk factors associated with the development of propofol-induced hypertriglyceridemia, defined as triglyceride level greater than or equal to 400 mg/dL. Minor outcomes included the prevalence of acute pancreatitis. A hybrid multivariate logistic regression analysis was used to evaluate the relation between individual risk factors and the dependent variable of hypertriglyceridemia. During the study period, 552 patients were evaluated for inclusion, of which 136 were included in the final analysis. A total of 38 patients (27.9%) developed hypertriglyceridemia with a median time to hypertriglyceridemia of 47 hours. The only significant independent risk factor for development of hypertriglyceridemia identified was the cumulative propofol dose (odds ratio, 1.04; 95% CI, 1.01–1.08; p = 0.016). Two of the 38 hypertriglyceridemia patients (5.3%) were diagnosed with acute pancreatitis.

Conclusions:

In our analysis, approximately one third of patients developed hypertriglyceridemia with cumulative propofol dose identified as a significant predictor of the development of hypertriglyceridemia. Despite a high incidence of hypertriglyceridemia, a significant number of patients continued propofol therapy, and a relatively low prevalence of pancreatitis was observed. Future analyses are warranted to further investigate these results.

A rare cause of pediatric acute pancreatitis: Perindopril intoxication

Acute pancreatitis is a reversible inflammatory condition of the pancreas. It usually develops on the basis of trauma, structural abnormalities, and chronic systemic diseases. A definitive causal correlation between a drug and acute pancreatitis is quite difficult for clinicians. Drugs play a vital role in the etiology in approximately 10% of children with pancreatitis. More than 50 drugs including angiotensin-converting enzyme inhibitors have been reported to cause pancreatic damage. There was no pediatric case report developed pancreatitis following perindopril use. A pediatric case of pancreatitis following perindopril intake was presented in this article to emphasize pancreatitis, which is one of the complications that may occur after drug intake.

Analysis of clinical characteristics of tigecycline-induced acute pancreatitis

WHAT IS KNOWN AND OBJECTIVE

The purpose of this study is to explore the clinical characteristics of tigecycline-induced acute pancreatitis.

METHODS

We searched the PubMed/Medline, Web of Knowledge, OVID, Elsevier, Springer Link, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Data, and Chinese VIP databases from 2005 and identified 19 studies of tigecycline-induced acute pancreatitis involving a total of 22 patients for inclusion in a retrospective analysis.

RESULTS AND DISCUSSION

The median (range) age of 22 patients with acute pancreatitis was 58 years (range 9-83). Overall, the median (range) time of symptom onset was 6.5 days (range 2-28), or 6 days (range 2-14) and 6 days (range 3-28) in patients with or without a loading dose of tigecycline, respectively. Symptoms included nausea, vomiting and abdominal distension (73%) and abdominal pain (73%); 90% (18/20) of patients developed mild acute pancreatitis (MAP), and 10% (2/20) developed severe acute pancreatitis (SAP). Computed tomography (CT) scans showed oedematous infiltrate in 56% (10/18) of cases and acute pancreatitis in 28% (5/18) of cases. The median (range) level of lipase and amylase was 936U/L (range 382-4089) and 588U/L (range 312-1166), respectively. The median (range) time to recovery of symptoms was 4 days (range 1-10), and the time for recovery of pancreatic enzymes to the normal range was 5 days (range 1-30) after the withdrawal of tigecycline in all patients.

WHAT IS NEW AND CONCLUSION

Clinicians should be particularly mindful of clinical signs and symptoms, the level of serum pancreatic enzymes and abdominal CT images in order to monitor the development of pancreatitis when using tigecycline.

Acute Pancreatitis Caused by Isotretinoin

Isotretinoin, a retinoid derivative, is used widely as a treatment for severe acne and other dermatological conditions. Its effect on lipid metabolism, especially the induction of hypertriglyceridemia, is well documented. There are some case reports in the literature about drug-induced pancreatitis secondary to isotretinoin. We describe another interesting case of acute pancreatitis related to severe hypertriglyceridemia due to isotretinoin.

Drug induced pancreatitis: A systematic review of case reports to determine potential drug associations

OBJECTIVE

A current assessment of case reports of possible drug-induced pancreatitis is needed. We systematically reviewed the case report literature to identify drugs with potential associations with acute pancreatitis and the burden of evidence supporting these associations.

METHODS

A protocol was developed a priori (PROSPERO CRD42017060473). We searched MEDLINE, Embase, the Cochrane Library, and additional sources to identify cases of drug-induced pancreatitis that met accepted diagnostic criteria of acute pancreatitis. Cases caused by multiple drugs or combination therapy were excluded. Established systematic review methods were used for screening and data extraction. A classification system for associated drugs was developed a priori based upon the number of cases, re-challenge, exclusion of non-drug causes of acute pancreatitis, and consistency of latency.

RESULTS

Seven-hundred and thirteen cases of potential drug-induced pancreatitis were identified, implicating 213 unique drugs. The evidence base was poor: exclusion of non-drug causes of acute pancreatitis was incomplete or poorly reported in all cases, 47% had at least one underlying condition predisposing to acute pancreatitis, and causality assessment was not conducted in 81%. Forty-five drugs (21%) were classified as having the highest level of evidence regarding their association with acute pancreatitis; causality was deemed to be probable or definite for 19 of these drugs (42%). Fifty-seven drugs (27%) had the lowest level of evidence regarding an association with acute pancreatitis, being implicated in single case reports, without exclusion of other causes of acute pancreatitis.

DISCUSSION

Much of the case report evidence upon which drug-induced pancreatitis associations are based is tenuous. A greater emphasis on exclusion of all non-drug causes of acute pancreatitis and on quality reporting would improve the evidence base. It should be recognized that reviews of case reports, are valuable scoping tools but have limited strength to establish drug-induced pancreatitis associations.

REGISTRATION

CRD42017060473.

Acute pancreatitis induced by Tadalafil: a case report

Acute pancreatitis is commonly caused by gallstones or alcohol abuse. Also, this complication has rarely been associated with other etiologies like drugs in some reports. We report the case of a 43-year-old man with 10-days history of taking Tadalafil for erectile dysfunction. The patient was presented to the emergency room with manifestations of acute pancreatitis. This diagnosis was confirmed after clinical examination, laboratory tests, and radiologic evaluation. Other probable etiological factors were ruled out. A total score of seven using Naranjo Adverse Drug Reaction Probability Scale clarifies a probable diagnosis of drug-induced acute pancreatitis in this case. The reported case of acute pancreatitis was most likely induced with Tadalafil.

Methods for the early detection of drug-induced pancreatitis: a systematic review of the literature

OBJECTIVES

We systematically reviewed the literature to identify evidence-informed recommendations regarding the detection of drug-induced pancreatitis (DIP) and, secondarily, to describe clinical processes for the diagnosis of DIP.

DESIGN

Systematic review.

DATA SOURCES

Ovid MEDLINE, including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase Classic+Embase, the Cochrane Library.

ELIGIBILITY CRITERIA

We included clinical practice guidelines, systematic reviews, narrative reviews and observational studies with a focus of establishing incidence, prevalence or diagnostic approaches for DIP. Clinical trials that diagnosed DIP as an outcome were also included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers screened citations and performed data extraction. A narrative synthesis of the evidence was prepared.

RESULTS

Fifty-nine studies were included. Early published evidence suggested serial pancreatic ultrasound could detect subclinical pancreatitis; however, subsequent studies demonstrated no utility of serial ultrasound or serial monitoring of pancreatic enzymes in the early detection of DIP. Two small studies conducted in patients with a high baseline risk of acute pancreatitis concluded serial monitoring of pancreatic enzymes may be useful to guide early discontinuation of medications with known associations with pancreatitis. Early discontinuation of medication was not advised for lower-risk patients because some medications cause transient elevations of pancreatic enzymes that do not progress to acute pancreatitis. Eight of 52 studies (15%) reporting a clinical diagnostic process for DIP reported using currently accepted criteria for the diagnosis of acute pancreatitis. A variety of methods were used to assess drug-related causality.

CONCLUSIONS

There is minimal evidence to support the use of serial monitoring by ultrasound or pancreatic enzymes to detect cases of DIP. Serial monitoring may be useful to guide early discontinuation of DIP-associated drugs in high-risk patients, but not in lower-risk patients. Greater uptake of standardised diagnostic and causality criteria for DIP is needed.

TRIAL REGISTRATION NUMBER

CRD42017060473.

Acute Pancreatitis Caused by Pemetrexed, Carboplatin, and Gemcitabine in a Patient with Lung Cancer: A Rare Case Report

Drug-induced pancreatitis is reported as one of the less common causes of acute pancreatitis. Many drugs such as sulfonamides, estrogens, tetracyclines, valproic acid, antiretroviral drugs, some chemotherapy drugs such as azathioprine, and 6 MP are known to cause acute pancreatitis. We report a case of acute pancreatitis following administration of chemotherapy for non-small cell lung cancer (NSCLC). The patient was diagnosed to have NSCLC (histologically proven adenocarcinoma). After thorough evaluation including radiological investigations consisting of a positron-emission tomography computed tomography scan, he was staged as a Stage III B NSCLC. As per protocol, he was started on combination chemotherapy with pemetrexed and carboplatin. After 2 weeks of chemotherapy, he developed acute pancreatitis which was managed conservatively. He was administered different drug combination during the next cycle involving gemcitabine and carboplatin. However, he developed recurrent acute pancreatitis which was managed conservatively. He was then referred to the radiotherapy department as it was deemed that he is at risk of recurrent episodes of pancreatitis if further cycles of chemotherapy are continued.

Metronidazole-Induced Pancreatitis: Is There Underrecognition? A Case Report and Systematic Review of the Literature

INTRODUCTION

Acute pancreatitis (AP) is the most common cause of gastroenterological hospitalization in the USA, with a mortality ranging from 5 to 20%. Up to 80% of cases are caused by cholelithiasis and alcohol abuse. Less common etiologies that need to be explored include hypertriglyceridemia, trauma, ERCP, infections, and drugs. A number of medications are known to cause acute pancreatitis, with 0.3-1.4% of all cases of pancreatitis being drug induced (DIP). Here, we present a case of metronidazole-induced acute pancreatitis.

CASE SUMMARY

A 60-year-old female presented with constant severe epigastric pain associated with nausea, vomiting, and anorexia for one day. She had no past medical history of alcohol use or hypertriglyceridemia and was s/p cholecystectomy in the distant past. Symptoms had begun three days after starting metronidazole for Clostridium difficile colitis. Lipase was > 396, and CT abdomen revealed peripancreatic fat stranding. She was diagnosed with AP, metronidazole was suspected to be responsible and hence stopped, and supportive management initiated. Her symptoms improved rapidly, and pancreatic enzymes normalized within 2 days. Of note, she had had an episode of acute pancreatitis 3 years ago, also following metronidazole use, with resolution at discontinuation of the drug. She had concurrently been on omeprazole during both episodes.

DISCUSSION

Metronidazole is a commonly used antibiotic and is infrequently reported as a cause of DIP. Our review suggests the possibility of a dose-response and duration-response effect between metronidazole use and occurrence of pancreatitis. The most common presenting symptom and sign was moderate to severe epigastric pain and tenderness, accompanied by nausea/vomiting. Symptoms usually start within 2-7 days of starting the medication and usually resolve 2-5 days after discontinuation of therapy and pancreatitis treatment. The most common causative dose was 1-1.5 g/day. Our review also supports findings by Norgaard et al. suggesting that concurrent use of omeprazole potentiates the risk of metronidazole-induced pancreatitis.

CONCLUSION

Metronidazole is a commonly used antibiotic that may cause metronidazole-induced pancreatitis, especially if patients are concurrently taking PPIs. Awareness needs to be raised amongst clinicians regarding this association, in order to correctly identify etiology of pancreatitis and discontinue metronidazole promptly when suspected as the causative factor.

Tigecycline-induced acute pancreatitis in a renal transplant patient: a case report and literature review

Background

The purpose of this case report is to increase the awareness of tigecycline-induced pancreatitis specifically in renal transplant patients predisposed to the condition.

Case presentation

A 48-year-old woman developed a donor-derived infection after kidney transplantation, resulting in a ruptured graft renal artery, followed by peritoneal drainage, blood and urine culture infections. Due to multiple drug resistance Acinetobacter baumannii cultured from the preservation fluid and blood, she was treated with tigecycline at the 8th post-transplant day combined with other antibiotics. After 15 days of tigecycline treatment, she was observed with recurrent fever and abdominal distension with a rise in pancreatic enzymes. CT scans showed acute pancreatitis with grade D on Balthazar score, no necrosis visible without contrast injection. These facts were sufficient to hint that pancreatitis was slowly becoming prominent. After withdrawal of tigecycline, CT scans showed that exudation around the pancreas were relieved, and blood amylase returned to the normal range in a week.

Conclusions

Clinicians should pay attention to clinical signs and symptoms and the level of serum pancreatic enzymes in order to monitor the development of pancreatitis. If necessary, abdominal CT scans should be performed regularly when given tigecycline.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3103-z) contains supplementary material, which is available to authorized users.

Relationship Between Acute Benzodiazepine Poisoning and Acute Pancreatitis Risk: A Population-Based Cohort Study

We designed a population-based retrospective cohort study to investigate the association between the event of benzodiazepine (BZD) poisoning and the risk of acute pancreatitis.In the present study, 12,893 patients with BZD poisoning during 2000 to 2011 were enrolled and matched with 4 comparison patients according to mean age and sex. We determined the cumulative incidences and adjusted hazard ratios of acute pancreatitis.A significant association was observed between BZD poisoning and acute pancreatitis. After adjustment for potential risk factors, the patients with BZD poisoning had a 5.33-fold increased risk of acute pancreatitis compared with the controls without BZD poisoning (HR = 5.33, 95% CI = 2.26-12.60). The results revealed that acute pancreatitis in patients with BZD poisoning occurred in a follow-up time of ≤1 month (HR = 50.0, P < .001), and the risk of acute pancreatitis was no different between the patients with and without BZD poisoning when the follow-up time was >1 month (HR = 1.07, P > .05).This population-based study revealed the positive correlation between the event of BZD poisoning and an increased risk of acute pancreatitis. The findings warrant further large-scale and in-depth investigation.

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.

A case of severe acute necrotizing pancreatitis after administration of sitagliptin

A 55-year-old Japanese man with a 3-year history of type 2 diabetes mellitus was admitted to our hospital for upper abdominal pain. Control of diabetes mellitus was good with voglibose and metformin, with sitagliptin added to this regimen 8 months prior. His pancreatic enzyme levels were elevated, and abdominal computed tomography (CT) showed diffuse pancreatic swelling with fluid accumulation and ascites of CT grade 3. The patient was diagnosed with severe acute pancreatitis. There were no obvious causes for pancreatitis except the recently administered sitagliptin. Since incretin-related drugs entered the market, the number of incretin-related drugs prescriptions rapidly increased and so did the incidence of pancreatitis. There are several reports suggesting the correlation between incretin-related drugs and pancreatitis, such as a report based on data obtained from the United States Food and Drug Administration (FDA) which revealed a significant correlation between the administration of exenatide or sitagliptin and pancreatitis. However, there also is a report that denied the evidence for such in a large cohort study. The relation between incretin based drugs and pancreatitis is still controversial.

L-asparaginase-induced pancreatic injury is associated with an imbalance in plasma amino acid levels

BACKGROUND

The use of L-asparaginase (ASNase) to modify amino acid metabolism is one of the most effective chemotherapeutic means of inducing remission in acute lymphoblastic leukemia (ALL). However, severe pancreatitis sometimes occurs in patients receiving ASNase, because of an unknown mechanism.

OBJECTIVE

The purpose of the present study was to evaluate the relationship between ASNase-induced pancreatic injury and plasma amino acid levels in patients undergoing ASNase therapy.

METHODS

A total of 29 children aged 1-13.25 years (median age 4 years; male : female ratio 19 : 10) with ALL, who received induction therapy according to the Tokyo Children's Cancer Study Group L04-16 protocol, were studied. Levels of plasma amino acids and serum rapid turnover proteins (RTPs), pancreatic enzymes, and pancreatic protease inhibitors were measured before and 1, 2, 3, 4, 5, and 7 weeks after the first administration of ASNase.

RESULTS

Plasma asparagine levels were significantly lower after the first injection of ASNase (p < 0.01) and had almost recovered 2 weeks after the last ASNase injection. At 4 weeks after the first ASNase injection, serum aspartic acid, trypsin, and pancreatic secretory trypsin inhibitor (PSTI) levels remained significantly higher than those before the first ASNase injection (p < 0.01), and serum levels of prealbumin and transferrin remained significantly lower than those before the first ASNase injection (p < 0.01). Plasma amino acid and serum RTP levels gradually normalized after the last ASNase injection.

CONCLUSIONS

Levels of serum trypsin and PSTI were elevated during the 2 weeks after administration of ASNase, which suggested the presence of subclinical pancreatitis. This period is similar to the time period in the present study when the levels of plasma amino acids changed, thus suggesting that ASNase-induced pancreatic injury could be caused by the imbalance of plasma amino acid levels.

Nontraumatic abdominal pain in pregnancy: imaging considerations for a multiorgan system problem

Nontraumatic abdominal pain in the pregnant patient can present a clinician with a variety of diagnostic possibilities. The overlap between signs and symptoms expected in normal pregnancy and these many pathologic possibilities does little to help focus the clinician's diagnostic efforts. Fear of ionizing radiation's effects on the fetus has driven efforts to refine medical imaging algorithms in such a way as to attempt to eliminate its use at all cost. In today's world, we are nearly there. In this review the differential diagnosis of nontraumatic abdominal pain in the pregnant patient will be explored. Of note is the recurring theme that much of what can be done today with regard to diagnostic imaging, both in general and with regard to this specific subset of patients, centers on the use of the non-ionizing modalities of ultrasound and magnetic resonance imaging.

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.

Atorvastatin-induced pancreatitis

Drugs account for 1–2% of all cases of pancreatitis. A 58-year-old man was prescribed atorvastatin 10 mg for 6 months for hyperlipidemia. He developed acute abdominal pain and vomiting with epigastric tenderness. Serum lipase and CT scan of the patient suggested the presence of acute pancreatitis. The patient was hospitalized; atorvastatin was stopped and treated symptomatically. He recovered completely within 10 days of drug withdrawal. The causality of the adverse drug reaction according to Naranjo and WHO-UMC Scale was probable. The exact mechanism of pancreatitis due to atorvastatin is not known. It may be a class effect of HMG CoA reductase inhibitors as it had been reported with other statins too. The definite causal relationship is difficult to establish, as rechallenge with the suspected drug was not done due to ethical consideration.

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

BACKGROUND

With the growing number of pharmacological agents available nowadays, the gastrointestinal drug-induced side effects become more common than ever. However, drug-induced pancreatitis belongs to rather seldom reported adverse drug reactions, probably because of the difficulty in proving the relationship between an inflammation of the pancreas and the pharmacotherapy with a certain drug.

AIM

The aim of this review is to draw attention to an infrequent but real problem of drug-induced acute pancreatitis associated with medications commonly used in the treatment of gastrointestinal disorders.

METHODOLOGY

For the purpose of that the PubMed database was searched using the keywords "drug-induced pancreatitis", "drug-associated pancreatitis", "acute pancreatitis", "pancreatitis" in various combinations and relevant literature was reviewed.

RESULTS

A substantial number of drugs commonly prescribed for gastrointestinal disorders are known to cause acute pancreatitis. Case reports and review articles published so far draw attention to medications already known to cause drug-induced pancreatic damage as well as implicate new drugs. Generally, the etiopathological mechanisms involved in drug-induced pancreatitis remain unclear. It is difficult to establish or rule out definitely such unwanted event, especially in patients taking numerous medications prescribed for multiple comorbidities.

CONCLUSION

Pharmacological agents are among etiologic factors that should be considered in all patients presenting with signs and symptoms consistent with acute pancreatitis. The diagnosis of drug-induced AP is often difficult to established. Therefore a high index of suspicion and thorough drug history are crucial for making the final diagnosis.

Incidence, severity, and etiology of drug-induced acute pancreatitis

INTRODUCTION

Drug-induced acute pancreatitis is considered to be a rare diagnosis. The incidence of drug-induced acute pancreatitis is usually estimated from case reports.

AIM

The aim of this study was to determine the incidence, etiology, and severity of drug-induced pancreatitis during a 2-year period in a tertiary hospital.

METHODS

The study was conducted as a retrospective analysis of all cases of pancreatitis in the University Hospital in Olomouc (1,432 beds) in 2006-2007. All cases of acute pancreatitis were re-evaluated and divided according to the causative factor. In drug-induced cases, the WHO Probability Scale for the evaluation of causality relationship was used.

RESULTS

The inclusion criteria were met by 170 medical files. There were 91 (53%) cases in men and 79 (47%) in women, and mean age was 57 years old (5-91 years old). The etiology was in 53% biliary, 31% alcohol-induced, 12% other determined, and in 4% the cause could not be established. The proportion of drug-induced acute pancreatitis was 5.3% and it was the third most frequent cause of the AP. Azathioprine was the most frequent causative factor (three cases in two patients); all the other causative drugs were documented only in single cases: mesalazine, dexamethasone, ramipril, mycophenolate mofetil, cytarabine, and valproate.

CONCLUSIONS

The diagnosis of drug-induced acute pancreatitis seems to be underestimated because of the difficulties in determining the causative agent and the need for a retrospective re-evaluation of the suspected causative factors. The disease is more probable in younger persons, women, and patients suffering from Crohn's disease.

Fungal pleural effusion secondary to a rare cause of pancreatic pseudocyst

We report a case of fungal pleural effusion secondary to presumed valproate induced pancreatitis with pseudocyst and stricture formation. A child with dyskinetic cerebral palsy who had been on sodium valproate for several years was transferred for drainage of a left sided pleural effusion. Pleural fluid culture consistently grew Candida glabrata although the patient was treated with broad-spectrum antibiotic and antifungal therapy. Clinical deterioration ensued with abdominal discomfort, feed intolerance, and re-accumulation of the effusion. Investigations revealed a large pancreatic pseudocyst compressing the stomach and impairing pancreatic function. Subsequent therapeutic evacuation of pancreatic fluid demonstrated C. glabrata. This case underscores that pleural disease may be secondary to abdominal pathology, and always to consider rare side-effects of medication in the face of a puzzling clinical picture.

Gastrointestinal complications of oncologic therapy

Gastrointestinal complications are common in patients undergoing various forms of cancer treatment, including chemotherapy, radiation therapy, and molecular-targeted therapies. Many of these complications are life-threatening and require prompt diagnosis and treatment. Complications of oncologic therapy can occur in the esophagus (esophagitis, strictures, bacterial, viral and fungal infections), upper gastrointestinal tract (mucositis, bleeding, nausea and vomiting), colon (diarrhea, graft-versus-host disease, colitis and constipation), liver (drug hepatotoxicity and graft-versus-host disease), and pancreas (pancreatitis). Treatment of the different gastrointestinal complications should be tailored to the individual patient and based on the underlying pathophysiology of the complication.

Review of idiopathic pancreatitis

Recent advances in understanding of pancreatitis and advances in technology have uncovered the veils of idiopathic pancreatitis to a point where a thorough history and judicious use of diagnostic techniques elucidate the cause in over 80% of cases. This review examines the multitude of etiologies of what were once labeled idiopathic pancreatitis and provides the current evidence on each. This review begins with a background review of the current epidemiology of idiopathic pancreatitis prior to discussion of various etiologies. Etiologies of medications, infections, toxins, autoimmune disorders, vascular causes, and anatomic and functional causes are explored in detail. We conclude with management of true idiopathic pancreatitis and a summary of the various etiologic agents. Throughout this review, areas of controversies are highlighted.

Ertapenem-induced acute pancreatitis in a surgical elderly patient

Case summary A 78-year old man was given, after surgery, 1 g ertapenem every 24 h intravenously. His clinical evolution was favorable and on day 8 ertapenem was discontinued and the patient was put on a semi-solid diet. On day 9, abdominal distension was seen accompanied by epigastric pain. The laboratory tests on day 8 showed an altered pancreatic profile: amylase = 1823 U/l (normal value: 0-100); lipase = 8045 U/l (normal value: 0-60); C-reactive protein (CRP) = 16.09 mg/dl (normal value: 0-0.5). Full Blood Count (FBC) showed leukocytosis with an increase in neutrophils and eosinophils. The prior pancreatic parameters were normal without leukocytosis. The evolution of clinical symptoms after discontinuing ertapenem was rapid. Between days 11 and 16, the laboratory parameters returned to normal values; the eosinophilia persisted longer, decreasing between days 14 and 16. Conclusions clinicians should include monitoring the development of acute pancreatitis in the safety parameters in patients undergoing treatment with this carbapenem.

Non-alcoholic etiologies of acute pancreatitis - exclusion of other etiologic factors besides alcohol and gallstones

The etiology of an attack of acute pancreatitis (AP) is highly variable. It is important to identify the causing factor, because it can have an effect on the specific treatment of AP. Furthermore, in some cases relapses of AP can be prevented when the causing factor is eliminated. The most common etiology of AP is alcohol abuse and gallstone disease (>80% of all cases). What diagnostic measures should be undertaken before an attack of AP is considered as idiopathic? Important factor in the etiologic diagnostic work-up is the availability, safety, and cost-effectiveness of suitable methods. Further, the relevance of the findings has to be assessed. In some cases also the age of the patient and number of attacks of AP (first vs. recurring) have effects on efforts to detect the causing factor of AP. This review focuses on the search for other etiologic factors once alcohol and gallstones have been excluded.

Ezetimibe-induced Acute Pancreatitis

Ezetimibe is a lipid-lowering agent that inhibits the intestinal absorption of cholesterol and other related phytosterols. It is used alone or in combination with other lipid-lowering agents in the treatment of various forms of hypercholesterolemia. Since its FDA approval in 2002, there are no known citations of ezetimibe-induced pancreatitis.

Suspected drug-induced destructive cholangitis in a young dog

A nine-month-old miniature doberman was referred for the evaluation of chronic icterus. History and clinical and histopathological findings were supportive of a diagnosis of drug-induced destructive cholangitis. The main histopathological findings were canalicular, centrilobular cholestasis and ductopenia with moderate inflammatory infiltrate. The dog had received three types of treatment for demodicosis before the onset of jaundice. Amoxicillin-clavulanate, amitraz, milbemycin oxime or an interaction between two of the three drugs may have been responsible for the destructive cholangitis.

Newer cyclo-oxygenase-2 selective inhibitors, other non-steroidal anti-inflammatory drugs and the risk of acute pancreatitis

BACKGROUND

Case reports have suggested that the use of newer cyclo-oxygenase-2 selective inhibitors may cause acute pancreatitis, but there has been no formal study of the association.

AIM

To assess the relationship between the use of cyclo-oxygenase-2 inhibitors and other non-steroidal anti-inflammatory drugs, and risk of acute pancreatitis.

METHODS

A population-based case-control study was conducted using hospital discharge and prescription data from Denmark. Using conditional logistic regression with adjustment for multiple covariates, we estimated the relative risk of acute pancreatitis for use of the cyclo-oxygenase-2 inhibitors celecoxib and rofecoxib and for other non-steroidal anti-inflammatory drugs.

RESULTS

A total of 3083 cases of acute pancreatitis and 30 830 population controls were identified. For current use the relative risk estimate for celecoxib was 1.4 (95% CI: 0.8-2.3) and for rofecoxib was 1.3 (95% CI: 0.7-2.3). The overall relative risk for other non-steroidal anti-inflammatory drugs was 2.7 (95% CI: 2.4-3.0) with a substantial variation in risk between the individual drugs. The highest relative risk was for diclofenac (odds ratio 5.0, 95% CI: 4.2-5.9) and the lowest for naproxen (odds ratio 1.1, 95% CI: 0.7-1.7).

CONCLUSION

Cyclo-oxygenase-2 selective inhibitors are associated with a lower risk of acute pancreatitis than most other non-steroidal anti-inflammatory drugs.

JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis

Acute pancreatitis is a common disease with an annual incidence of between 5 and 80 people per 100,000 of the population. The two major etiological factors responsible for acute pancreatitis are alcohol and cholelithiasis (gallstones). The proportion of patients with pancreatitis caused by alcohol or gallstones varies markedly in different countries and regions. The incidence of acute alcoholic pancreatitis is considered to be associated with high alcohol consumption. Although the incidence of alcoholic pancreatitis is much higher in men than in women, there is no difference in sexes in the risk involved after adjusting for alcohol intake. Other risk factors include endoscopic retrograde cholangiopancreatography, surgery, therapeutic drugs, HIV infection, hyperlipidemia, and biliary tract anomalies. Idiopathic acute pancreatitis is defined as acute pancreatitis in which the etiological factor cannot be specified. However, several studies have suggested that this entity includes cases caused by other specific disorders such as microlithiasis. Acute pancreatitis is a potentially fatal disease with an overall mortality of 2.1%-7.8%. The outcome of acute pancreatitis is determined by two factors that reflect the severity of the illness: organ failure and pancreatic necrosis. About half of the deaths in patients with acute pancreatitis occur within the first 1-2 weeks and are mainly attributable to multiple organ dysfunction syndrome (MODS). Depending on patient selection, necrotizing pancreatitis develops in approximately 10%-20% of patients and the mortality is high, ranging from 14% to 25% of these patients. Infected pancreatic necrosis develops in 30%-40% of patients with necrotizing pancreatitis and the incidence of MODS in such patients is high. The recurrence rate of acute pancreatitis is relatively high: almost half the patients with acute alcoholic pancreatitis experience a recurrence. When the gallstones are not treated, the risk of recurrence in gallstone pancreatitis ranges from 32% to 61%. After recovering from acute pancreatitis, about one-third to one-half of acute pancreatitis patients develop functional disorders, such as diabetes mellitus and fatty stool; the incidence of chronic pancreatitis after acute pancreatitis ranges from 3% to 13%. Nevertheless, many reports have shown that most patients who recover from acute pancreatitis regain good general health and return to their usual daily routine. Some authors have emphasized that endocrine function disorders are a common complication after severe acute pancreatitis has been treated by pancreatic resection.

Propofol-Associated Hypertriglyceridemia and Pancreatitis in the Intensive Care Unit: An Analysis of Frequency and Risk Factors

STUDY OBJECTIVES

To characterize the frequency, severity, risk factors, and clinician response to propofol-associated hypertriglyceridemia and hypertriglyceridemia-associated pancreatitis.

DESIGN

Retrospective analysis.

SETTING

Medical and surgical intensive care units.

PATIENTS

One hundred fifty-nine adult intensive care patients administered propofol for 24 hours or longer and who had at least one serum triglyceride concentration.

MEASUREMENTS AND MAIN RESULTS

Patient records were reviewed to identify the frequency of hypertriglyceridemia (serum triglyceride concentration > or = 400 mg/dl) and pancreatitis (amylase concentration > or = 125 IU/L, lipase concentration > or = 60 IU/L, and abdominal computed tomography scan or clinical examination findings consistent with pancreatitis). Of the 159 patients, 29 (18%) developed hypertriglyceridemia; six (21%) of the 29 had a serum triglyceride concentration of 1000 mg/dl or greater. The median maximum serum triglyceride concentration was 696 mg/dl (range 403-1737 mg/dl). At the time when hypertriglyceridemia was detected, the median infusion rate of propofol was 50 microg/kg/minute (range 5-110 microg/kg/min). The median time from the start of propofol therapy to identification of hypertriglyceridemia was 54 hours (range 14-319 hrs). Propofol was discontinued within 24 hours of detecting the hypertriglyceridemia 84% of the time. Compared with those who did not develop hypertriglyceridemia, patients who developed hypertriglyceridemia were older, had a longer intensive care unit stay, and received propofol for a longer duration; they were also more likely to be admitted to the medical versus the surgical intensive care unit. Pancreatitis developed in three (10%) of the 29 patients with hypertriglyceridemia.

CONCLUSION

Hypertriglyceridemia and hypertriglyceridemia-associated pancreatitis are often seen in intensive care patients receiving propofol. Serum triglyceride concentrations should be routinely monitored in these patients. In addition, alternative sedation strategies should be considered when hypertriglyceridemia is detected.

Acute pancreatitis associated with combined lisinopril and atorvastatin therapy

Few data exist about the incidence of drug-induced pancreatitis in the general population. Drugs are related to the etiology of pancreatitis in about 1.4-2% of cases. Although statins are generally well tolerated, acute pancreatitis has been reported in a few cases treated with atorvastatin, fluvastatin and simvastatin. A 86-year-old man with long-standing history of hypertension and hyperlipidemia, who was treated with lisinopril 10 mg and atorvastatin 20 mg once daily presented with acute pancreatitis. Other causes of the disease were ruled out. After cessation of the drugs, his physical condition improved and the amylase level decreased. To our knowledge, pancreatitis induced by a combination of atorvastatin together with lisinopril has never been reported in the literature.

Pancreatitis, complicated by a pancreatic pseudocyst associated with the use of valproic acid

A 12-year-old boy developed pancreatitis, complicated by a pancreatic pseudocyst, as an adverse reaction to valproic acid (VPA) treatment for epilepsy. Pancreatitis subsided within three weeks after discontinuation of VPA. The pancreatic pseudocyst was managed without surgery and resolved spontaneously in four weeks. Valproic acid was concluded to be the most probable cause, since no other explanation was found. According to the literature VPA is a rare but known cause of pancreatitis. A computer-assisted literature search revealed seven previously reported cases of VPA-induced pancreatitis complicated by a pancreatic pseudocyst. Six of these patients were under 20 years of age. Four patients were treated conservatively; three needed cystostomy or external drainage. All patients recovered. Patients using VPA, especially children, presenting with acute abdominal pain should be suspected of valproic acid-induced pancreatitis. If VPA induced pancreatitis is complicated by a pseudocyst, conservative treatment should be the first line of treatment.

Pancreatitis causing death in bulimia nervosa

OBJECTIVE

We report the case of a 19-year-old woman with bulimia nervosa who died of acute hemorrhagic pancreatitis. Our objective is to raise awareness that because the symptoms of both conditions are very similar, the pre-existence of an eating disorder should not distract physicians from the possibility that potentially lethal acute pancreatitis may coexist.

METHOD

The study includes autopsy results and a review of the literature.

RESULTS

Pancreatitis usually presents with abdominal pain, nausea, and vomiting.

DISCUSSION

In patients with eating disorders who may already have exhibited these symptoms pancreatitis may not be considered. Elevated serum amylase values may occur in subjects with bulimia nervosa without pancreatitis. If the serum amylase value is elevated, pancreatitis can be confirmed by measuring the levels of serum lipase, trypsinogen, pancreatic isoenzyme of amylase, or by abdominal computerized tomography (CT).

Are drugs a risk factor of post-ERCP pancreatitis?

BACKGROUND

Pancreatitis is the most severe complication of ERCP. The aim of this study was to assess whether the use of potentially pancreatotoxic drugs is a risk factor for post-ERCP pancreatitis.

METHODS

Risk factors for post-ERCP pancreatitis and all drugs taken during the month before ERCP were recorded retrospectively in a database. Patients with other causes of acute pancreatitis or chronic pancreatitis were excluded from the analysis. Post-ERCP pancreatitis was defined as abdominal pain and/or vomiting associated with amylase/lipase plasma levels equal to or greater than twice the upper normal value.

RESULTS

A total of 173 patients (95 men, 78 women; mean age, 68 [16] years) were included. Post-ERCP pancreatitis occurred in 31 patients (18%). Several risk factors were identified in a multivariate analysis: difficulty in cannulation (p<0.001), endoscopic sphincterotomy (p<0.005), and female gender (p=0.02). Having taken potent pancreatotoxic drugs increased the occurrence of post-ERCP pancreatitis: odds ratio 3.7: 95% confidence intervals [1.1,12.4], p=0.04.

CONCLUSIONS

Use of pancreatotoxic drugs before or during ERCP significantly increased the risk of post-ERCP pancreatitis. Thus, discontinuation of the use of such drugs before ERCP seems justified whenever possible.

Dapsone-Induced Acute Pancreatitis

OBJECTIVE

To report a case of acute pancreatitis associated with dapsone use.

CASE SUMMARY

An 87-year-old white man was prescribed dapsone for dermatitis herpetiformis. Four weeks later, he developed acute abdominal pain requiring hospitalization. The patient had elevated serum amylase and lipase levels. Laboratory test results for other possible etiologies were negative. His symptoms resolved when dapsone was discontinued. Dapsone was reintroduced for exacerbation of dermatitis herpetiformis 4 months later. The patient again had severe abdominal pain with high amylase and lipase levels. Again, symptoms resolved following dapsone discontinuation.

DISCUSSION

Only 1 other case of pancreatitis associated with dapsone was found in a MEDLINE search of the literature (1966-June 2003) using the key terms dapsone and pancreatitis. An objective causality assessment revealed dapsone to be a probable cause of acute pancreatitis, based on the Naranjo probability scale. Drugs should always be considered as causative factors for pancreatitis in patients without known risk factors. Dapsone is increasingly used as a second line of treatment of Pneumocystis carinii pneumonia (PCP). The recognition of dapsone-induced pancreatitis is of particular importance in these patients.

CONCLUSIONS

While dapsone is traditionally used for the treatment of leprosy and dermatitis herpetiformis, its use for PCP prophylaxis, malaria, brown recluse spider bites, and acne is not uncommon. Pancreatitis is an uncommon adverse effect of dapsone, and greater awareness of this association will prompt a high index of suspicion in an appropriate clinical setting. Further reporting of cases and clinical research of drug-induced pancreatitis is indicated.