Acute pancreatitis associated with combined lisinopril and atorvastatin therapy

Etiology and severity features of acute pancreatitis in HIV-positive patients with different immune status

Objectives

Acute pancreatitis is common in HIV-infected patients; however, the causes and severity of pancreatitis in HIV-positive patients have a number of significant features that affect both the severity of destruction of the pancreas and the methods of diagnosis and treatment.

Material and Methods

Anamnestic data, results of diagnosis and treatment of two groups of patients with acute pancreatitis were analyzed. The first group included 79 patients with acute pancreatitis combined with HIV infection who were admitted to the clinic for the period from 2017 to 2021. In people living with HIV, drugs and infectious agents caused acute pancreatitis in 11.4% and 24.1% of the cases, respectively. As our study showed, in patients with normal immune status, the drug etiology of pancreatitis prevailed in the structure of the causes of AP, in patients with immunodeficiency, infectious causes of pancreatitis were dominant.

Results

According to the results of data analysis, it is clear that HIV infection is a factor that makes the course of pancreatitis about two times worse regardless of the presence of immunosuppression. The etiological structure of HIV-associated acute pancreatitis directly depends on the patient's immune status and differs in many ways from that of HIV-negative patients or patients receiving ART.

Conclusion

The severity of the disease and the risk of death remain high in acute pancreatitis caused by infectious agents against the background of immunosuppression.

Pravastatin-Induced Acute Pancreatitis: A Case Report and Literature Review

Pancreatitis is inflammation of pancreas associated most commonly with chronic alcoholism and gallstones. Other less common causes of pancreatitis are hyperlipidemia, infections, surgery, trauma, post endoscopic retrograde cholangiopancreatography, and drugs. Drugs are now increasingly recognized as a cause of pancreatitis, and high suspicion and exclusion of other most common causes is required before considering drug-induced pancreatitis. There are few case reports of acute pancreatitis in the literature after statin use, but out of these, only 3 are after starting pravastatin. We are reporting a case of 49-year-old male who presented with nausea, vomiting, and abdominal pain. His laboratory findings were significant for lipase more than 10 000 on admission, and computed tomography scan of abdomen was showing peripancreatic fat stranding and inflammation. After exclusion of most common causes of pancreatitis, pravastatin was found probable culprit for his symptoms, which he started taking 2 weeks ago. We also reviewed the literature on statins-induced acute pancreatitis. With increased uses of statins, physician need to be vigilant to suspect statins as a culprit in cases of pancreatitis with unknown etiology. Prompt discontinuation of statins is required in these cases.

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.

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.

Atorvastatin-induced acute pancreatitis

Atorvastatin-induced acute pancreatitis (AP) is one of the rare adverse effects available in the literature. We report a case of 53-year-old patient developed AP after treatment with atorvastatin monotherapy which resolved after drug withdrawal. Extensive workup on AP failed to reveal any other etiology for it. To our knowledge, this is one of the rare case reports of AP caused due to atorvastatin monotherapy and it further strengthens the fact that statins may cause AP. There is need of continued reporting of such a rare adverse effect of atorvastatin for increasing awareness and to manage and avoid the same.

Metformin-induced lactic acidosis and acute pancreatitis precipitated by diuretic, celecoxib, and candesartan-associated acute kidney dysfunction

Polypharmacy may lead to synergistic complications from the different medications. We report the case of a 50-year-old woman who was prescribed 11 drugs, including a diuretic, celecoxib, metformin, and candesartan, and who developed acute kidney dysfunction while on these drugs, manifesting as severe proteinuria, acute azotemia, hyperkalemia. The kidney injury caused the accumulation of metformin, leading to lactic acidosis and acute pancreatitis. Sodium bicarbonate hemodialysis not only improved the metabolic abnormalities but also hastened the removal of metformin.

Lisinopril-induced acute pancreatitis

Drugs are an uncommon but well-recognised cause of acute pancreatitis and new agents of drug-induced pancreatitis continue to be reported. We describe only the 10th reported case of lisinopril-induced pancreatitis in a young female patient.

Statin adverse effects : a review of the literature and evidence for a mitochondrial mechanism

HMG-CoA reductase inhibitors (statins) are a widely used class of drug, and like all medications, have potential for adverse effects (AEs). Here we review the statin AE literature, first focusing on muscle AEs as the most reported problem both in the literature and by patients. Evidence regarding the statin muscle AE mechanism, dose effect, drug interactions, and genetic predisposition is examined. We hypothesize, and provide evidence, that the demonstrated mitochondrial mechanisms for muscle AEs have implications to other nonmuscle AEs in patients treated with statins. In meta-analyses of randomized controlled trials (RCTs), muscle AEs are more frequent with statins than with placebo. A number of manifestations of muscle AEs have been reported, with rhabdomyolysis the most feared. AEs are dose dependent, and risk is amplified by drug interactions that functionally increase statin potency, often through inhibition of the cytochrome P450 3A4 system. An array of additional risk factors for statin AEs are those that amplify (or reflect) mitochondrial or metabolic vulnerability, such as metabolic syndrome factors, thyroid disease, and genetic mutations linked to mitochondrial dysfunction. Converging evidence supports a mitochondrial foundation for muscle AEs associated with statins, and both theoretical and empirical considerations suggest that mitochondrial dysfunction may also underlie many nonmuscle statin AEs. Evidence from RCTs and studies of other designs indicates existence of additional statin-associated AEs, such as cognitive loss, neuropathy, pancreatic and hepatic dysfunction, and sexual dysfunction. Physician awareness of statin AEs is reportedly low even for the AEs most widely reported by patients. Awareness and vigilance for AEs should be maintained to enable informed treatment decisions, treatment modification if appropriate, improved quality of patient care, and reduced patient morbidity.

Drug-induced acute pancreatitis: an evidence-based review

The diagnosis of drug-induced acute pancreatitis often is difficult to establish. Although some medications have been shown to cause acute pancreatitis with a large body of evidence, including rechallenge, some medications have been attributed as a cause of acute pancreatitis merely by a single published case report in which the investigators found no other cause. In addition, some medications reported to have caused acute pancreatitis have obvious patterns of presentation, including the time from initiation to the development of disease (latency). There also appear to be patterns in the severity of disease. After reviewing the literature, we have classified drugs that have been reported to cause acute pancreatitis based on the published weight of evidence for each agent and the pattern of clinical presentation. Based on our analysis of the level of evidence, 4 classes of drugs could be identified. Class I drugs include medications in which at least 1 case report described a recurrence of acute pancreatitis with a rechallenge with the drug. Class II drugs include drugs in which there is a consistent latency in 75% or more of the reported cases. Class III drugs include drugs that had 2 or more case reports published, but neither a rechallenge nor a consistent latency period. Class IV drugs were similar to class III drugs, but only 1 case report had been published. Our analysis allows an evidence-based approach when suspecting a drug as causing acute pancreatitis.

Statins and pancreatitis: a systematic review of observational studies and spontaneous case reports

Many anecdotal reports have suggested that therapy with HMG-CoA reductase inhibitors ('statins') can cause acute pancreatitis. We aimed to quantify the association between statins and pancreatitis and to classify the adverse effect under the dose, time, susceptibility (DoTS) system. We searched for controlled observational studies that assessed the risk of pancreatitis in patients receiving statins. In order to identify case reports of statin-induced pancreatitis, we looked for reports published in scientific journals and manually reviewed reports within the Canadian Adverse Drug Event Monitoring System (CADRMP) database. Two observational studies were identified and the data pooled together in a meta-analysis. This yielded an odds ratio of 1.41 (95% CI 1.15, 1.74) for the risk of acute pancreatitis in patients with a past history of exposure to statins. We also identified 20 published case reports and 33 spontaneous reports from the CADRMP database. These data showed that pancreatitis can occur at both high and low doses, with 12 cases developing pancreatitis at less than the dose equivalent of simvastatin 20 mg daily. Statin-induced pancreatitis can occur at any time but seems to be very uncommon early on and more likely to occur after many months of therapy. There does not appear to be a cumulative dose effect and increasing age does not appear to be a major susceptibility factor. These finding should help clinicians to better manage and diagnose patients who are at risk of statin-induced pancreatitis.

Recurrent Acute Pancreatitis Probably Secondary to Lisinopril

OBJECTIVES

Few data exist about the incidence of drug-induced acute pancreatitis in the general population. Although angiotensin-converting enzymes are generally well tolerated, acute pancreatitis has been reported in a few subjects treated with captopril, enalapril, and lisinopril. However, to our knowledge, there is no published data regarding recurrent pancreatitis secondary to lisinopril. Herein, we report the case of a 54-year-old man who developed recurrent acute pancreatitis after starting lisinopril.

CLINICAL PRESENTATION

A 54-year-old man with a longstanding history of hypertension, treated with lisinopril 10 mg once daily, presented with acute pancreatitis. Other causes of the disease were ruled out. After cessation of lisinopril, his condition improved and his amylase level decreased. This was his third episode of acute pancreatitis since lisinopril had been started in 2002. After discontinuing lisinopril and beginning treatment with amlodipine 10 mg/d, the patient was well at follow-up examination and has not had another episode of pancreatitis during the subsequent 7 months.

CONCLUSION

This case report demonstrates additional evidence of acute pancreatitis associated with an ACE inhibitor.

A case of simvastatin-associated pancreatitis and review of statin-associated pancreatitis

Reduction of low-density lipoprotein cholesterol (LDL) concentration has become the primary goal and a standard of care in the practice of cholesterol management. The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statins, are the most frequently prescribed lipid lowering agents on the market. As more information is learned through the results of clinical trials, LDL goals become more stringent and difficult to attain. Large doses of high-potency statins, sometimes given in combination with other lipid-lowering agents, are frequently necessary to achieve these goals. As a result, the frequency of adverse effects from statin therapy may be expected to increase, and less common adverse effects may occur more often. As statins are used more aggressively, rare and possibly dangerous adverse effects must be identified, especially those that are becoming more frequently encountered. Increased awareness may lead to earlier diagnosis and management of diseases that may be caused by the statins. We describe a 58-year-old man who was hospitalized with idiopathic pancreatitis 4 months after starting simvastatin therapy. His oral drug therapy was withheld, and he was treated with bowel rest. The patient was discharged on hospital day 5, and his oral drug regimen, including simvastatin, was resumed. He was admitted again 16 months later with a second diagnosis of acute pancreatitis and was discharged after 3 days of bowel rest with no oral drug therapy. Simvastatin was restarted on discharge, but the patient stopped taking it after experiencing muscle soreness and weakness in his arms. He recalled having similar arm pain that preceded the previous episode of acute pancreatitis. All other causes of the pancreatitis had been ruled out; thus, the correlation between simvastatin-induced myalgia and onset of acute pancreatitis on two separate occasions made simvastatin the suspected instigating agent. Pancreatitis is a rare adverse effect of statin therapy, but it has been documented in several case reports involving most of the statins. Continued reporting is necessary to increase awareness of this rare adverse effect of simvastatin so that it may be promptly managed or avoided in the future.