Efficacy and tolerance of metamizole versus morphine for acute pancreatitis pain

Management of analgesia in acute pancreatitis: Results of a national survey

INTRODUCTION

Acute pancreatitis is one of the main reasons for digestive admissions. Adequate pain treatment is crucial in its management. However, there are hardly any descriptions of the analgesic guidelines used in our setting.

METHODS

On-line survey on analgesic management in acute pancreatitis, aimed at attending physicians and residents practising in Spain.

RESULTS

Two hundred and nine physicians from 88 centres responded to the survey. Ninety percent were specialists in gastrointestinal medicine and 69% worked in a tertiary centre. The majority (64.4%) do not routinely use scales to measure pain. When choosing a drug, experience in its use was the most important factor. The most commonly prescribed initial treatments are: combination of paracetamol and metamizole (53.5%), paracetamol alone (19.1%) and metamizole alone (17.4%). As rescue: meperidine (54.8%), tramadol (17.8%), morphine chloride (17.8%) and metamizole (11.5%). Continuous perfusion is used in 8.2% of initial treatments. Physicians with >10 years of service use more metamizole as monotherapy (50%), while residents and attending physicians with <10 years of service prescribe it in combination with paracetamol (85%). If progression is needed, morphine chloride and meperidine are mainly used. The speciality of the respondent, the size of the work centre and the unit/service where the patients were admitted did not influence the analgesia prescribed. Satisfaction with pain management reached 7.8/10 (SD 0.98).

CONCLUSION

In our setting, metamizole and paracetamol are the most commonly used analgesics as initial pain treatment in acute pancreatitis, and meperidine is the most commonly used rescue analgesic.

Current trends in acute pancreatitis: Diagnostic and therapeutic challenges

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.

Controversies in the management of acute pancreatitis: An update

This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

Revised Clinical Practice Guidelines of the Korean Pancreatobiliary Association for Acute Pancreatitis

Acute pancreatitis can range from a mild, self-limiting disease requiring no more than supportive care, to severe disease with life-threatening complications. With the goal of providing a recommendation framework for clinicians to manage acute pancreatitis, and to contribute to improvements in national health care, the Korean Pancreatobiliary Association (KPBA) established the Korean guidelines for acute pancreatitis management in 2013. However, many challenging issues exist which often lead to differences in clinical practices. In addition, with newly obtained evidence regarding acute pancreatitis, there have been great changes in recent knowledge and information regarding this disorder. Therefore, the KPBA committee underwent an extensive revision of the guidelines. The revised guidelines were developed using the Delphi method, and the main topics of the guidelines include the following: diagnosis, severity assessment, initial treatment, nutritional support, convalescent treatment, and the treatment of local complications and necrotizing pancreatitis. Specific recommendations are presented, along with the evidence levels and recommendation grades.

The Efficacy and Safety of Using Opioids in Acute Pancreatitis: an Update on Systematic Review and Meta-Analysis

Background

Most patients with acute pancreatitis (AP) suffer from abdominal pain that requires immediate pain relief, and there are various medication choices available, with opioids being the most prescribed analgesics.

Objective

Our objective is to compare the use of opioids with other medications in emergency settings for managing pain in patients with AP.

Methods

A systemic search was conducted in electronic databases (PubMed/Medline, Cochrane Library, Embase and Google Scholar) from inception to Feb 2023. All statistical analyses were conducted in Review Manager 5.4.1. The study's inclusion criteria was then selected. Only those Randomized Controlled Trials were involved that included patients having AP in an emergency setting. A random-effect model was used when heterogeneity was seen to pool the studies, and the result was reported in the Odds Ratio (OR) and Mean Difference (MD) along with the corresponding 95% confidence interval (CI). Narrative analysis was conducted for those variables which did not have sufficient data be included in the quantitative analysis.

Results

We include eight Randomized Controlled Trials in our study. The Pooled result showed non-significant differences in adverse effects between the two interventions (OR 1.42 [95% CI 0.62, 3.23]; p value= 0.40; I2= 20%). While overall, significantly additional drugs were used in the control group (OR 0.22 [95% CI 0.06, 0.85]; p value= 0.03; I2= 72%). Pain score and severity levels were also analyzed. We used a narrative approach to analyze the length of stay, mean time to reach significant decrease in pain, and mortality, which were all non-conclusive. We also narratively assessed the Pediatric population.

Conclusion

Opioids do not provide significant superiority over other medications and should be avoided due to their addictive nature.

Safety and efficacy of intravenous hydromorphone patient-controlled analgesia versus intramuscular pethidine in acute pancreatitis: An open-label, randomized controlled trial

Background: Hydromorphone patient-controlled analgesia (PCA) provides satisfactory postoperative pain therapy, but its effect has not been assessed in acute pancreatitis (AP).

Aim: To assess the safety and efficacy of intravenous hydromorphone PCA for pain relief in AP.

Methods: This open-label trial included AP patients admitted within 72 h of symptom onset, aged 18–70 years old, and with Visual Analog Scale (VAS) for pain intensity ≥5. They were randomized to receive intravenous hydromorphone PCA (0.05 mg/h with 0.2 mg on-demand) or intramuscular pethidine (50 mg as required) for three consecutive days. Intramuscular dezocine (5 mg on demand) was the rescue analgesia. The primary outcome was the change of VAS score recorded every 4 h for 3 days. Interim analysis was conducted by an Independent Data and Safety Monitoring Committee (IDSMC).

Results: From 26 July 2019 to 15 January 2020, 77 patients were eligible for the intention-to-treat analysis in the interim analysis (39 in the hydromorphone group and 38 in the pethidine group). Baseline parameters were comparable between groups. No difference in VAS between the two groups was found. Hydromorphone PCA was associated with higher moderately severe to severe cases (82.1% vs. 55.3%, p = 0.011), acute peripancreatic fluid collections (53.9% vs. 28.9%, p = 0.027), more cumulative opioid consumption (median 46.7 vs. 5 mg, p &lt; 0.001), higher analgesia costs (median 85.5 vs. 0.5 $, p &lt; 0.001) and hospitalization costs (median 3,778 vs. 2,273 $, p = 0.007), and more adverse events (20.5% vs. 2.6%, p = 0.087). The per-protocol analysis did not change the results. Although a sample size of 122 patients was planned, the IDSMC halted further recruitment as disease worsening or worse clinical outcomes between the groups in the interim analysis.

Conclusion: Hydromorphone PCA was not superior to pethidine in relieving pain in AP patients and might have worse clinical outcomes. Therefore, its use is not recommended.

Clinical Trial Registration: Chictr.org.cn. ChiCTR1900025971

The Association Between Opioid Use and Opioid Type and the Clinical Course and Outcomes of Acute Pancreatitis

OBJECTIVES

Basic science studies suggest that opioids aggravate disease severity and outcomes in acute pancreatitis. We sought to determine the association of opioid use and opioid type with the clinical course and outcome of acute pancreatitis.

METHODS

In this retrospective single-center observational study, we included all adult patients admitted with acute pancreatitis between 2008 and 2021. Patients were classified into 3 groups based on analgesia type: morphine, noonmorphine opioid, and nonopioid.

RESULTS

We included 2308 patients. Of the patients, 343 (14.9%) were treated with morphine, 733 (31.8%) were treated with nonmorphine opioids, and 1232 (53.4%) patients were in the nonopioid group. The incidence of 30-day mortality did not differ significantly between study groups: 3.9%, 2.9%, and 4.4% in the nonopioid, nonmorphine-opioid, and morphine groups, respectively ( P = 0.366).In multivariate analysis, the composite end point consisting of 30-day mortality, invasive ventilation, emergent abdominal surgery, and need for vasopressors was significantly more likely to occur in the morphine group than in the nonopioid group (adjusted odds ratio, 1.69; 95% confidence interval, 1.1-2.598; P = 0.01).

CONCLUSIONS

Mortality among acute pancreatitis patients did not differ significantly between patients receiving morphine, nonmorphine opioids, and nonopioids. However, morphine treatment was associated with higher rates of some serious adverse events.

Prior Exposure to Nonsteroidal Anti-inflammatory Drugs Reduces the Rate of Organ Failure and In-Hospital Mortality in Acute Pancreatitis

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been linked recently to a lower expression of pro-inflammatory cytokines in humans with acute pancreatitis. Because it is unclear if this effect results in clinical benefits, the aim of this study was to determine if prior NSAID exposure improves immediate clinical outcomes.

METHODS

Retrospective medical record review of adult patients admitted with acute pancreatitis. Cases were extracted from a national Veterans Affairs database using International Classification of Diseases, Ninth Revision codes. Prior NSAIDs use was determined through pharmacy data claims. The rates of acute kidney injury, respiratory failure, cardiovascular failure, and in-hospital mortality were compared between those with prior NSAID use (AP+NSAID) and those without it (AP-NSAID) using univariate and multivariate analysis.

RESULTS

A total of 31,340 patients were identified: 28,364 AP+NSAID and 2976 AP-NSAID. The median age was 60 years, 68% were white, and the median hospital stay was 4 days. Approximately 2% of patients died during the hospitalization. After adjusting for demographics and other covariates, patients in the AP+NSAID arm had lower rates of acute kidney injury, P = .0002), cardiovascular failure (P = .025), any organ failure (P ≤ .0001), and in-hospital mortality (P < .0001).

CONCLUSION

Prior use of NSAIDs is associated with a lower incidence of organ failure and in-hospital mortality in adult patients with acute pancreatitis. The role of NSAIDs as therapeutic agents in this condition should be evaluated in interventional trials.

Fentanyl but Not Morphine or Buprenorphine Improves the Severity of Necrotizing Acute Pancreatitis in Rats

Opioids are widely used for the pain management of acute pancreatitis (AP), but their impact on disease progression is unclear. Therefore, our aim was to study the effects of clinically relevant opioids on the severity of experimental AP. Various doses of fentanyl, morphine, or buprenorphine were administered as pre- and/or post-treatments in rats. Necrotizing AP was induced by the intraperitoneal injection of L-ornithine-HCl or intra-ductal injection of Na-taurocholate, while intraperitoneal caerulein administration caused edematous AP. Disease severity was determined by laboratory and histological measurements. Mu opioid receptor (MOR) expression and function was assessed in control and AP animals. MOR was expressed in both the pancreas and brain. The pancreatic expression and function of MOR were reduced in AP. Fentanyl post-treatment reduced necrotizing AP severity, whereas pre-treatment exacerbated it. Fentanyl did not affect the outcome of edematous AP. Morphine decreased vacuolization in edematous AP, while buprenorphine pre-treatment increased pancreatic edema during AP. The overall effects of morphine on disease severity were negligible. In conclusion, the type, dosing, administration route, and timing of opioid treatment can influence the effects of opioids on AP severity. Fentanyl post-treatment proved to be beneficial in AP. Clinical studies are needed to determine which opioids are best in AP.

Analgesia in the Initial Management of Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown.

OBJECTIVE

The present systematic review and meta-analysis aims to compare the efficacy of different analgesic modalities trialled in AP.

METHODS

A systematic search of PubMed, MEDLINE, EMBASE, CENTRAL, SCOPUS and Web of Science conducted up until June 2021, identified all randomised control trials (RCTs) comparing analgesic modalities in AP. A pooled analysis was undertaken of the improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2.

RESULTS

Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), metamizole, local anaesthetic, epidural, paracetamol, and placebo. Across all modalities, the pooled VAS scores showed global improvement from baseline to day 2. Epidural analgesia appears to provide the greatest improvement in VAS within the first 24 h but is equivalent to opiates by 48 h. Within 24 h, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant statistical and methodological heterogeneity in pain-relief reporting.

CONCLUSIONS

There is remarkable paucity of level 1 evidence to guide pain management in AP with small datasets per study. Epidural administration appears effective within the first 24 h of AP although infrequently used and featured in only a single RCT. NSAIDs are an effective opiate sparing alternative during the first 24 h.

Pain Management in Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Background: Pain management is an important priority in the treatment of acute pancreatitis (AP). Current evidence and guideline recommendations are inconsistent on the most effective analgesic protocol. This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to compare the safety and efficacy of analgesics for pain relief in AP.

Methods: A literature search was performed to identify all RCTs assessing analgesics in patients with AP. The primary outcome was the number of participants who needed rescue analgesia. Study quality was assessed using Jadad score. Pooled odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CI) were analysed using a random-effects model.

Results: Twelve studies comprising 699 patients with AP (83% mild AP) were analysed. The tested analgesics significantly decreased the need for rescue analgesia (3 studies, OR.36, 95% CI 0.21 to 0.60) vs. placebo or conventional treatment. The analgesics also improved the pain score [Visual Analogue Scale (Δ-VAS)] at 24 h (WMD 18.46, 0.84 to 36.07) and by the 3rd to 7th days (WMD 11.57, 0.87 to 22.28). Opioids vs. non-opioids were associated with a decrease in the need for rescue analgesia (6 studies, OR 0.25, 95% CI 0.07 to 0.86, p = 0.03) but without significance in pain score. In subgroup analyses, opioids were similar to non-steroidal anti-inflammatory drugs (NSAIDs) regarding the primary outcome (4 studies, OR 0.56, 95% CI 0.24 to 1.32, p = 0.18). There were no significant differences in other clinical outcomes and rate of adverse events. Other studies, comparing epidural anaesthesia vs. patient-controlled analgesia and opioid (buprenorphine) vs. opioid (pethidine) did not show significant difference in primary outcome. Study quality issues significantly contributed to overall study heterogeneity.

Conclusions: NSAIDs and opioids are equally effective in decreasing the need for rescue analgesia in patients with mild AP. The relative paucity of trials and high-quality data in this setting is notable and the optimal analgesic strategy for patients with moderately severe and severe AP still requires to be determined.

A systematic review of NSAIDs treatment for acute pancreatitis in animal studies and clinical trials

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently given to patients with acute pancreatitis (AP) for controlling pain, but their efficacy in treating AP, particularly in reducing systemic complications, remains unclear.

AIM

The aim of our study was to evaluate the efficacy of NSAIDs in treating AP and its systematic complications.

METHODS

Two independent reviewers screened articles from MEDLINE, Embase and Cochrane and scored the quality of each study according to the CAMARADES 10-item quality checklist or the Jadad scale. Five endpoints were chosen to evaluate the effect of NSAIDs in animal studies: amylase and lipase levels, proinflammatory cytokines, oxidative damage, histopathological changes, and mortality rate. Meanwhile, in clinical studies, endpoints, such as proinflammatory cytokines, pain relief, systematic complications, mortality, and adverse events were used.

RESULTS

A total of 36 studies out of 17,845 were identified and included. Of these 36 studies, only 5 were clinical trials involving 580 patients, and the remaining 31 were animal studies with 1623 rats or mice. 24 studies focused on the treatment of AP with NSAIDs and 12 on AP-associated systematic complications. Both preclinical and clinical studies showed that NSAIDs may have beneficial effects against AP-related injuries. 9 of the 14 preclinical studies stated that NSAIDs reduced the serum amylase level significantly, and 6 of 7 showed that NSAIDs lowered the lipase level markedly. 17 experimental studies all demonstrated that NSAIDs reduced the inflammation. Histopathological examinations indicated that NSAIDs significantly improved the histopathological damages. Similarly, clinical evidence showed that NSAIDs are effective in suppressing proinflammatory cytokines, relieving pain, ameliorating systematic complications and reducing mortality. In the included 5 clinical studies, serious adverse events associated with NSAIDs were rarely reported.

CONCLUSION

This systematic review shows that NSAIDs are a potential treatment for AP-related injuries based on the current preclinical and clinical evidences.

Okra pectin relieves inflammatory response and protects damaged intestinal barrier in caerulein-induced acute pancreatic model

BACKGROUND

Protecting the intestinal mucosa from being destroyed helps reduce the inflammation caused by acute pancreatitis (AP). In this study, whether okra pectin (OP) could attenuate the inflammation of AP through protecting the intestinal barrier was investigated.

RESULTS

OP was obtained from crude okra pectin (COP) through the purification by DEAE cellulose 52 column. Supplementation with OP or COP in advance reduced the severity of AP, as revealed by lower serum amylase and lipase levels, abated pancreatic edema, attenuated myeloperoxidase activity and pancreas histology. OP or COP inhibited the production of pancreatic proinflammatory cytokines, including tumor necrosis factor-α and interleukin-6. In addition, the upregulation of AP-related proteins including ZO-1, occludin, the antibacterial peptide-defensin-1 (DEFB1) and cathelicidin-related antimicrobial peptide (CRAMP), as well as the histological examination of colon injuries, demonstrated that OP or COP provision could effectively maintain intestinal barrier function. Ultimately, dietary OP or COP supplementation could inhibit AP-induced intestinal inflammation. For the above, the effect of OP was better than COP.

CONCLUSION

Dietary OP supplementation could be considered as a preventive method that effectively interferes with intestinal damage and attenuates inflammatory responses trigged by AP. © 2020 Society of Chemical Industry.

Analysis of Animal Well-Being When Supplementing Drinking Water with Tramadol or Metamizole during Chronic Pancreatitis

Simple Summary

Pain management during in vivo experiments can considerably improve the wellbeing of animals. However, often it is not clear, which drugs are best for the animals and how to apply these drugs without causing stress. In this study, we evaluated mice when metamizole or tramadol was provided via drinking water. Neither of these two drugs reduced the amount of consumed water or body weight in healthy mice or influenced their natural behavior, such as nest building or burrowing activity. Both analgesics were then given to mice suffering from chronic pancreatitis. Mice drinking tramadol supplemented water, at some time-points, experienced less loss in body weight and consumed more water than mice drinking metamizole. However, no major differences in other methods measuring wellbeing of mice was observed. In conclusion, both analgesics can be used during chronic pancreatitis, but tramadol seems to be moderately advantageous when compared to metamizole.

Abstract

Pain management during in vivo experiments is an animal welfare concern and is in many countries also legally required. In this study, we evaluated C57Bl/6J mice when 3 g/L metamizole or 1 g/L tramadol was provided via drinking water, before and during cerulein-induced chronic pancreatitis. Supplementation of drinking water with metamizole or tramadol did not significantly reduce the amount of consumed water. In order to evaluate the wellbeing of mice, a distress score, burrowing activity, nesting behavior, and body weight was assessed. Before induction of pancreatitis, neither tramadol nor metamizole influenced these readout parameters. Chronic pancreatitis caused a significantly increased distress score, decreased burrowing activity and a reduction in body weight. Mice drinking tramadol-supplemented water experienced less loss in body weight and consumed more water than mice drinking metamizole, at a few time-points during chronic pancreatitis. Pancreatic atrophy, a characteristic feature of chronic pancreatitis was not differentially influenced by either analgesic. In conclusion, both analgesics can be used during 33 days of chronic pancreatitis, but tramadol seems to be moderately advantageous when compared to metamizole.

Approaching acute pain in emergency settings; European Society for Emergency Medicine (EUSEM) guidelines-part 2: management and recommendations

BACKGROUND

In Europe, healthcare systems and education, as well as the clinical care and health outcomes of patients, varies across countries. Likewise, the management of acute events for patients also differs, dependent on the emergency care setting, e.g. pre-hospital or emergency department. There are various barriers to adequate pain management and factors common to both settings including lack of knowledge and training, reluctance to give opioids, and concerns about drug-seeking behaviour or abuse. There is no single current standard of care for the treatment of pain in an emergency, with management based on severity of pain, injury and local protocols. Changing practices, attitudes and behaviour can be difficult, and improvements and interventions should be developed with barriers to pain management and the needs of the individual emergency setting in mind.

METHODS

With these principles at the forefront, The European Society for Emergency Medicine (EUSEM) launched a programme-the European Pain Initiative (EPI)-with the aim of providing information, advice, and guidance on acute pain management in emergency settings.

RESULTS AND CONCLUSIONS

This article provides treatment recommendations from recently developed guidelines, based on a review of the literature, current practice across Europe and the clinical expertise of the EPI advisors. The recommendations have been developed, evaluated, and refined for both adults and children (aged ≥ 1 year, ≤ 15 years), with the assumption of timely pain assessment and reassessment and the possibility to implement analgesia. To provide flexibility for use across Europe, options are provided for selection of appropriate pharmacological treatment.

Worldwide Variations in Demographics, Management, and Outcomes of Acute Pancreatitis

BACKGROUND & AIMS

Few studies have compared regional differences in acute pancreatitis. We analyzed data from an international registry of patients with acute pancreatitis to evaluate geographic variations in patient characteristics, management, and outcomes.

METHODS

We collected data from the APPRENTICE registry of patients with acute pancreatitis, which obtains information from patients in Europe (6 centers), India (3 centers), Latin America (5 centers), and North America (8 centers) using standardized questionnaires. Our final analysis included 1612 patients with acute pancreatitis (median age, 49 years; 53% male, 62% white) enrolled from August 2015 through January 2018.

RESULTS

Biliary (45%) and alcoholic acute pancreatitis (21%) were the most common etiologies. Based on the revised Atlanta classification, 65% of patients developed mild disease, 23% moderate, and 12% severe. The mean age of patients in Europe (58 years) was older than mean age for all 4 regions (46 years) and a higher proportion of patients in Europe had comorbid conditions (73% vs 50% overall). The predominant etiology of acute pancreatitis in Latin America was biliary (78%), whereas alcohol-associated pancreatitis accounted for the highest proportion of acute pancreatitis cases in India (45%). Pain was managed with opioid analgesics in 93% of patients in North America versus 27% of patients in the other 3 regions. Cholecystectomies were performed at the time of hospital admission for most patients in Latin America (60% vs 15% overall). A higher proportion of European patients with severe acute pancreatitis died during the original hospital stay (44%) compared with the other 3 regions (15%).

CONCLUSIONS

We found significant variation in demographics, etiologies, management practices, and outcomes of acute pancreatitis worldwide. ClinicalTrials.gov number: NCT03075618.

Opioid use disorder in admissions for acute exacerbations of chronic pancreatitis and 30-day readmission risk: A nationwide matched analysis

BACKGROUND

The opioid epidemic in the United States has been on the rise. Acute exacerbations of chronic pancreatitis (AECP) patients are at higher risk for Opioid Use Disorder (OUD). Evidence on OUD's impact on healthcare utilization, especially hospital re-admissions is scarce. We measured the impact of OUD on 30-day readmissions, in patients admitted with AECP from 2010 to 2014.

METHODS

This is a retrospective cohort study which included patients with concurrently documented CP and acute pancreatitis as first two diagnoses, from the National Readmissions Database (NRD). Pancreatic cancer patients and those who left against medical advice were excluded. We compared the 30-day readmission risk between OUD-vs.-non-OUD, while adjusting for other confounders, using multivariable exact-matched [(EM); 18 confounders; n = 28,389] and non-EM regression/time-to-event analyses.

RESULTS

189,585 patients were identified. 6589 (3.5%) had OUD. Mean age was 48.7 years and 57.5% were men. Length-of-stay (4.4 vs 3.9 days) and mean index hospitalization costs ($10,251 vs. $9174) were significantly higher in OUD-compared to non-OUD-patients (p < 0.001). The overall mean 30-day readmission rate was 27.3% (n = 51,806; 35.3% in OUD vs. 27.0% in non-OUD; p < 0.001). OUD patients were 25% more likely to be re-admitted during a 30-day period (EM-HR: 1.25; 95%CI: 1.16-1.36; p < 0.001), Majority of readmissions were pancreas-related (60%), especially AP. OUD cases' aggregate readmissions costs were $23.3 ± 1.5 million USD (n = 2289).

CONCLUSION

OUD contributes significantly to increased readmission risk in patients with AECP, with significant downstream healthcare costs. Measures against OUD in these patients, such as alternative pain-control therapies, may potentially alleviate such increase in health-care resource utilization.

Comparison of efficacy of diclofenac and tramadol in relieving pain in patients of acute pancreatitis: A randomized parallel group double blind active controlled pilot study

BACKGROUND

Opioids and non steroidal anti inflammatory drugs (NSAIDs) are commonly used for pain relief in acute pancreatitis (AP). Opioids carry risk of sphincter of oddi constriction. Although diclofenac prevents post endoscopic retrograde cholangio-pancreatography (ERCP) pancreatitis, few reports of diclofenac associated AP are also present. Although, both tramadol and diclofenac are commonly used for pain relief in AP, no study has evaluated their comparative efficacy and safety.

MATERIALS AND METHODS

Forty-six eligible participants were randomized to either diclofenac or tramadol. Primary objectives of our study were improvement in pain intensity on visual analogue scale (VAS pain score after 1 hr of drug administration) and number of patients requiring supplementary analgesia. The secondary objectives were total number of times of supplementary analgesia requirement, time to significant decrease (33%) in VAS pain score from baseline, number of painful days (VAS pain score >5), VAS pain score on 7th day, side effects, all cause death and complications of pancreatitis between the two groups.

RESULTS

Although 46 patients were randomized, the final analysis included 41 participants. Five patients were withdrawn from the study (intubation = 3, altered sensorium = 2). No significant difference was seen in terms of VAS score after 1 hr of drug administration, number of patients requiring supplementary analgesic and number of painful days. However, time taken to significant reduction of pain was lower in the diclofenac group (p = .028). Both the agents were comparable in terms of safety. Although complications were less in the diclofenac group, the difference was not statistically significant.

CONCLUSION

Both diclofenac and tramadol are equally effective in controlling pain in AP with similar safety profile.

SIGNIFICANCE

There are no studies that have compared the safety and efficacy of two commonly used analgesics for pain relief in patients with AP. We found that both diclofenac and tramadol are equally effective in decreasing the pain associated with AP. There is also no significant difference in the incidence of side effects between both the groups. Hence both diclofenac and tramadol can be used safely and effectively for pain control in AP.

TRIAL REGISTRATION

The trial was registered with clinical trials registry India (Number- CTRI/2018/05/014309).

Current status of diagnosis and Mesenchymal stem cells therapy for acute pancreatitis

Acute pancreatitis (AP) is an acute gastrointestinal disorder that is the most common and requiring emergency hospitalization. Its incidence is increasing worldwide, thus increasing the burden of medical services. Approximately 20% of the patients develop moderate to severe necrotizing pancreatitis associated with pancreatic or peri-pancreatic tissue necrosis and multiple organ failure. There are many reports about the anti-inflammatory effect of mesenchymal stem cells (MSCs) on pancreatitis and the repair of tissue damage. MSCs cells come from a wide range of sources, autologous MSCs come from bone marrow and allogeneic MSCs such as umbilical cord blood MSCs, placenta-derived MSCs, etc. The wide source is not only an advantage of MSCs but also a disadvantage of MSCs. Because of different cell sources and different methods of collection and preparation, it is impossible to establish a unified standard method for evaluation of efficacy. The biggest advantage of iMSCs is that it can be prepared by a standardized process, and can be prepared on a large scale, which makes it easier to commercialize. This paper reviews the present status of diagnosis and progress of MSCs therapy for AP.

Pharmacologic management and prevention of acute pancreatitis

PURPOSE OF REVIEW

The present article will focus in pharmacologic agents that have been studied to improve acute pancreatitis outcomes, and to prevent the disease at different levels.

RECENT FINDINGS

Too little and too much early fluid resuscitation can be harmful. The optimal volume, rate, and duration of intravenous fluid therapy is still unknown. Nonopioid analgesics should be the first line of analgesia in patients with acute pancreatitis. A few pharmacologic agents evaluated in acute pancreatitis have resulted in positive pilot trials; however, larger randomized clinical trials (RCTs) are needed before final conclusions. Statin use is associated with lower incidence of acute pancreatitis in the general population and ongoing studies are evaluating its preventive role in acute pancreatitis recurrences. The preventive role of rectal indomethacin in post-endoscopic retrograde cholangiopancreatography pancreatitis is indisputable, with subject selection and timing of administration requiring further investigation.

SUMMARY

There is still no proven effective disease-specific pharmacologic therapy that changes the natural history of acute pancreatitis. New therapeutic targets and pharmacologic agents are in the horizon. Careful refinement in study design is needed when planning future RCTs. There is also a need for drug development aiming at reducing the incidence of the disease and preventing its sequelae.

Pentazocine, a Kappa-Opioid Agonist, Is Better Than Diclofenac for Analgesia in Acute Pancreatitis: A Randomized Controlled Trial

OBJECTIVES

The ideal analgesic is not known for patients with acute pancreatitis (AP). Concerns have been raised about serious adverse effects of opioid analgesics increasing the severity of AP. We hypothesized that nonsteroidal anti-inflammatory drugs might be better analgesics because of their anti-inflammatory effect. Our objective was to compare pentazocine, an opioid, and diclofenac, a nonsteroidal anti-inflammatory drug, for adequate analgesia in patients with AP.

METHODS

In a double-blind randomized controlled trial, patients with AP were randomized to either intravenous diclofenac 75 mg or pentazocine 30 mg. Fentanyl was given as a rescue analgesic through a patient-controlled analgesia pump. Primary outcome was pain relief measured objectively by the dose of fentanyl required as the rescue analgesic, pain-free period, and numbers of effective and ineffective demands of fentanyl. Secondary outcome was adverse events.

RESULTS

Fifty patients were randomized, 24 to the pentazocine group and 26 to the diclofenac group. Baseline characteristics were comparable between the groups. Pentazocine was found to be better than diclofenac in terms of significantly lower dose of the rescue analgesic (fentanyl) required (126 μg (interquartile range (IQR) 65-218 μg) vs 225.5 μg (IQR 133-427 μg); P = 0.028) and longer pain-free period (31.1 ± 8.2 vs 27.9 ± 6.6 hours, P = 0.047). The number of effective and ineffective demands was lower in the pentazocine group compared with the diclofenac group (11.5 (IQR 8-15) vs 16 (IQR 13-20), P = 0.098) although not statistically significant. Adverse events were similar between the groups.

CONCLUSIONS

Pentazocine, a kappa-opioid receptor agonist, was significantly better than diclofenac for pain relief in AP (Trial registration number: CTRI/2016/09/007326).

Enhanced Recovery in Mild Acute Pancreatitis: A Randomized Controlled Trial

OBJECTIVES

Acute pancreatitis (AP) is a leading cause of hospitalization for a gastrointestinal illness in the United States. We hypothesized that enhanced recovery approaches may lead to earlier time to refeeding in patients with AP.

METHODS

We performed a double-blind, randomized controlled trial of patients admitted with mild AP from July 2016 to April 2017 at a tertiary medical center. Participants were randomly assigned to receive either enhanced recovery consisting of nonopioid analgesia, patient-directed oral intake, and early ambulation versus standard treatment with opioid analgesia and physician-directed diet. Primary study end point was time to oral refeeding on an intent-to-treat basis. Secondary end points included differences in pancreatitis activity scores, morphine equivalents, length of stay, and 30-day readmissions.

RESULTS

Forty-six participants enrolled. Median age was 53.1 years, and 54.3% were female. There was significant reduction in time to successful oral refeeding in the enhanced recovery versus standard treatment group (median, 13.8 vs 124.8 hours, P < 0.001). Pancreatitis activity scores trended lower at 48 to 96 hours among patients assigned to enhanced recovery (mean, 43.6 vs. 58.9, P = 0.32). No differences found in length of stay or 30-day readmissions.

CONCLUSION

In this randomized controlled trial, enhanced recovery was safe and effective in promoting earlier time to refeeding in patients hospitalized with AP.

Postmarketing cases of eluxadoline-associated pancreatitis in patients with or without a gallbladder

BACKGROUND

Cases of pancreatitis were identified in the eluxadoline clinical development program, reflected in initial product labelling, and the subject of postmarketing reports.

AIM

To analyse postmarketing cases of eluxadoline-associated pancreatitis.

METHODS

We retrospectively analysed all US adverse event reports of pancreatitis associated with eluxadoline reported to the FDA Adverse Event Reporting System (FAERS) database from May 27, 2015 through February 15, 2017.

RESULTS

The analysis included 119 cases of pancreatitis associated with eluxadoline; one resulted in death and 75 in hospitalisation. Sixty-seven cases reported the presence (n = 12) or absence (n = 55) of the patient's gallbladder. The eluxadoline dose received in the 55 cases of patients without gallbladders was 75 mg (n = 43), 100 mg (n = 5), or not reported (n = 7). Of the 119 cases, 37 reported the patient did not abuse alcohol and 82 did not report the alcohol abuse status. The single fatal case occurred in a patient without a gallbladder who received eluxadoline 75 mg and did not abuse alcohol. Forty-seven cases reported development of pancreatitis within the first or second dose of eluxadoline initiation. The median time to onset for the development of pancreatitis (n = 83) was 1 day, ranging from 1 to 56 days of continued use of eluxadoline.

CONCLUSION

The FAERS cases suggest that patients with or without a gallbladder receiving eluxadoline are at risk for the development of pancreatitis. However, patients without a gallbladder, despite receiving the recommended lower dose of eluxadoline 75 mg and screening for alcohol abuse, appear to be overrepresented among patients who developed eluxadoline-associated pancreatitis.

Risk of Pancreatitis Following Treatment of Irritable Bowel Syndrome With Eluxadoline

BACKGROUND & AIMS

The Food and Drug Administration approved eluxadoline for the treatment of diarrhea-predominant irritable bowel syndrome despite cases of pancreatitis in early stage trials. We investigated the frequency of pancreatitis attributed to eluxadoline in postmarketing surveillance.

METHODS

We extracted reports on eluxadoline submitted to the Federal Adverse Event Reporting System from January through September 2016. We collected data on patient age and sex, event date, reporting entity (consumer, physician, pharmacist, legal worker, or other), medications, dosages, presumed role in the event (coinciding, primary, or secondary suspect), treatment indication, and outcome (death, life threatening, hospitalization, disability, or other).We compared data for eluxadoline with data from antidiarrheals, oxycodone, and rifaximin using the κ² test, Kruskal-Wallis rank test, and analysis of variance; findings with P < .05 were considered statistically significant.

RESULTS

Pancreatitis accounted for 16.4% of the 597 reports of adverse events linked to eluxadoline; 53 cases required hospitalization. Pancreatitis was listed as treatment complication of other agents in significantly lower proportions of cases (loperamide, 0.3%; diphenoxylate, 0.4%; oxycodone, 0.2%; rifaximin, 0.5%), with 75% of these submissions not considering the agent as causal.

CONCLUSIONS

In an analysis of reports on eluxadoline submitted to the Federal Adverse Event Reporting System, we confirmed a previously reported risk of pancreatitis associated with eluxadoline. The need for hospitalization in at least half of these instances and a recent report of 2 fatalities should prompt reassessments of the agent's risk-benefit ratio.

Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee

BACKGROUND

Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed.

METHODS

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation.

RESULTS

The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP.

CONCLUSIONS

This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.

Acute pancreatitis: recent advances through randomised trials

Acute pancreatitis is one of the most common GI conditions requiring acute hospitalisation and has a rising incidence. In recent years, important insights on the management of acute pancreatitis have been obtained through numerous randomised controlled trials. Based on this evidence, the treatment of acute pancreatitis has gradually developed towards a tailored, multidisciplinary effort, with distinctive roles for gastroenterologists, radiologists and surgeons. This review summarises how to diagnose, classify and manage patients with acute pancreatitis, emphasising the evidence obtained through randomised controlled trials.

Early management of acute pancreatitis: A review of the best evidence

In the 20th century early management of acute pancreatitis often included surgical intervention, despite overwhelming mortality. The emergence of high-quality evidence (randomized controlled trials and meta-analyses) over the past two decades has notably shifted the treatment paradigm towards predominantly non-surgical management early in the course of acute pancreatitis. The present evidence-based review focuses on contemporary aspects of early management (which include analgesia, fluid resuscitation, antibiotics, nutrition, and endoscopic retrograde cholangiopancreatography) with a view to providing clear and succinct guidelines on early management of patients with acute pancreatitis in 2017 and beyond.

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015

BACKGROUND

Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines.

METHODS

A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines.

RESULTS

Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles.

CONCLUSIONS

The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.

Metamizole-associated adverse events: a systematic review and meta-analysis

Background

Metamizole is used to treat pain in many parts of the world. Information on the safety profile of metamizole is scarce; no conclusive summary of the literature exists.

Objective

To determine whether metamizole is clinically safe compared to placebo and other analgesics.

Methods

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and several clinical trial registries. We screened the reference lists of included trials and previous systematic reviews. We included randomized controlled trials that compared the effects of metamizole, administered to adults in any form and for any indication, to other analgesics or to placebo. Two authors extracted data regarding trial design and size, indications for pain medication, patient characteristics, treatment regimens, and methodological characteristics. Adverse events (AEs), serious adverse events (SAEs), and dropouts were assessed. We conducted separate meta-analyses for each metamizole comparator, using standard inverse-variance random effects meta-analysis to pool the estimates across trials, reported as risk ratios (RRs). We calculated the DerSimonian and Laird variance estimate T² to measure heterogeneity between trials. The pre-specified primary end point was any AE during the trial period.

Results

Of the 696 potentially eligible trials, 79 trials including almost 4000 patients with short-term metamizole use of less than two weeks met our inclusion criteria. Fewer AEs were reported for metamizole compared to opioids, RR = 0.79 (confidence interval 0.79 to 0.96). We found no differences between metamizole and placebo, paracetamol and NSAIDs. Only a few SAEs were reported, with no difference between metamizole and other analgesics. No agranulocytosis or deaths were reported. Our results were limited by the mediocre overall quality of the reports.

Conclusion

For short-term use in the hospital setting, metamizole seems to be a safe choice when compared to other widely used analgesics. High-quality, adequately sized trials assessing the intermediate- and long-term safety of metamizole are needed.

Acute pancreatitis in children and adolescents

In this Topic Highlight, the causes, diagnosis, and treatment of acute pancreatitis in children are discussed. Acute pancreatitis should be considered during the differential diagnosis of abdominal pain in children and requires prompt treatment because it may become life-threatening. The etiology, clinical manifestations, and course of acute pancreatitis in children are often different than in adults. Therefore, the specific features of acute pancreatitis in children must be considered. The etiology of acute pancreatitis in children is often drugs, infections, trauma, or anatomic abnormalities. Diagnosis is based on clinical symptoms (such as abdominal pain and vomiting), serum pancreatic enzyme levels, and imaging studies. Several scoring systems have been proposed for the assessment of severity, which is useful for selecting treatments and predicting prognosis. The basic pathogenesis of acute pancreatitis does not greatly differ between adults and children, and the treatments for adults and children are similar. In large part, our understanding of the pathology, optimal treatment, assessment of severity, and outcome of acute pancreatitis in children is taken from the adult literature. However, we often find that the common management of adult pancreatitis is difficult to apply to children. With advances in diagnostic techniques and treatment methods, severe acute pancreatitis in children is becoming better understood and more controllable.

Nutrition, inflammation, and acute pancreatitis

Acute pancreatitis is acute inflammatory disease of the pancreas. Nutrition has a number of anti-inflammatory effects that could affect outcomes of patients with pancreatitis. Further, it is the most promising nonspecific treatment modality in acute pancreatitis to date. This paper summarizes the best available evidence regarding the use of nutrition with a view of optimising clinical management of patients with acute pancreatitis.

Opioids for acute pancreatitis pain

BACKGROUND

Acute pancreatitis is an acute inflammatory process of the pancreas that may also involve adjacent tissues and/or remote organ systems. Abdominal pain is the main symptom and is usually accompanied by nausea, vomiting and fever. Opoids are commonly used to manage pain in acute pancreatitis but there are still some uncertainties about their clinical effectiveness and safety.

OBJECTIVES

To assess the effectiveness and safety of opioids for treating acute pancreatitis pain.

SEARCH METHODS

The search strategy included the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 6), MEDLINE (from 1950 to June 2013) and EMBASE (from 1980 to June 2013). There were no restrictions by language or publication status.

SELECTION CRITERIA

We considered randomised clinical trials (RCTs) assessing the effectiveness of any opioid drug used for treating acute pancreatitis pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RRs) for dichotomous data and calculated a 95% confidence interval (CI) for each RR. We performed an intention-to-treat (ITT) analysis. We undertook meta-analysis for some outcomes.

MAIN RESULTS

We included five RCTs with a total of 227 participants (age range 23 to 76 years; 65% men) with acute pancreatitis pain. The opioids assessed were intravenous and intramuscular buprenorphine, intramuscular pethidine, intravenous pentazocine, transdermal fentanyl and subcutaneous morphine.One RCT, comparing subcutaneous morphine with intravenous metamizole reported non-significant reduction in the number of participants with improvements in pain intensity (primary outcome) (RR 0.50, 95% CI 0.19 to 1.33). Three studies compared analgesia using opioids with non-opioid treatments. After excluding one study that used opioids through continuous intravenous infusion, there was a decrease in the number of patients requiring supplementary analgesia (RR 0.53, 95% CI 0.30 to 0.93). In a single study, there were no differences in the number of patients requiring supplementary analgesia between buprenorphine and pethidine (RR 0.82, 95% CI 0.61 to 1.10).Pancreatitis complications were not associated with a significant difference between the drugs tested. No clinically serious or life-threatening adverse events occurred related to treatment. No differences for this outcome were found between opioid and non-opioid treatments, or for type of adverse event (nausea-vomiting and somnolence-sedation). One death in the procaine group was reported across all the trials.One RCT comparing pethidine with intramuscular buprenorphine reported non-significant differences of supplementary analgesic, adverse events or deaths. One RCT comparing fentanyl with placebo found no difference in adverse events.The findings of this review are limited by the lack of information to allow full appraisal of the risk of bias, the measurement of relevant outcomes and the small numbers of participants and events covered by the trials.

AUTHORS' CONCLUSIONS

Opioids may be an appropriate choice in the treatment of acute pancreatitis pain. Compared with other analgesic options, opioids may decrease the need for supplementary analgesia. There is currently no difference in the risk of pancreatitis complications or clinically serious adverse events between opioids and other analgesia options.Future research should focus on the design of trials with larger samples and the measurement of relevant outcomes for decision-making, such as the number of participants showing reductions in pain intensity. The reporting of these RCTs should also be improved to allow users of the medical literature to appraise their results accurately. Large longitudinal studies are also needed to establish the risk of pancreatitis complications and adverse events related to drugs.

Parenteral analgesics for pain relief in acute pancreatitis: a systematic review

AIM

To assess the efficiency and safety of parenteral analgesics for pain relief in acute pancreatitis.

MATERIALS AND METHODS

We carried out an electronic search of PubMed, Cochrane Library, EMBASE, WEIPU, CNKI and CBM and a manual search for eligible studies. The methodological quality of included trials and quality of evidence were examined by the Cochrane Collaboration's tool for assessing risk of bias and GRADE, respectively. The data were mainly analyzed descriptively and some were pooled by Review manager 5.

RESULTS

Eight randomized controlled trials with a total of 356 patients were finally included in this systematic review. Compared with procaine, pentazocine led to lower pain severity: day 1, Mean Difference (MD), 95%CI: 40.0 [35.3, 44.7]; day 2, MD, 95%CI: 24.00 [20.88, 27.12]; day 3, MD, 95%CI: 5.00 [2.17, 7.83], and it decreased the requirement for additional analgesics, Relative Risk, 95%CI: 2.23 [1.63, 3.05]. The combination of fentanyl, atropine, droperidol and lidocaine rendered lower pain score: day 1, MD, 95%CI: -5.46 [-6.95, -3.97]; day 2, MD, 95%CI: -5.78 [-7.39, -4.17]. Patients treated with metamizole tended to had lower pain than those treated with morphine, MD, 95%CI: -2.60 [-2.95, -2.25]. Nausea, emesis and vomiting were the common adverse events reported and there was almost no significant difference between different agents on safety.

CONCLUSIONS

The systemic review showed that the randomized controlled trials comparing different analgesics were of low quality and did not favor clearly any particular analgesic for pain relief in acute pancreatitis.

Pancreatic nociception--revisiting the physiology and pathophysiology

BACKGROUND

Pain management of many pancreatic diseases remains a major clinical concern. This problem reflects our poor understanding of pain signaling from the pancreas.

OBJECTIVES

This review provides an overview of our current knowledge, with emphasis on current pain management strategies and recent experimental findings.

METHODS

A systematic search of the scientific literature was carried out using EMBASE, PubMed/MEDLINE, and the Cochrane Central Register of Controlled Trials for the years 1965-2011 to obtain access to all publications, especially randomized controlled trials, systematic reviews, and meta-analyses exploring pain and its management in disease states such as acute pancreatitis (AP), chronic pancreatitis (CP) and pancreatic cancer (PC).

RESULTS

Over the last decade, numerous molecular mediators such as nerve growth factor and the transient receptor potential (TRP) cation channel family have been implicated in afferent nerve signaling. More recent animal studies have indicated the location of the receptive fields for the afferent nerves in the pancreas and shown that these are activated by agents including cholecystokinin octapeptide, 5-hydroxytryptamine and bradykinin. Studies with PC specimens have shown that neuro-immune interactions occur and numerous agents including TRP cation channel V1, artemin and fractalkine have been implicated. Experimental studies in the clinical setting have demonstrated impairment of inhibitory pain modulation from supraspinal structures and implicated neuropathic pain mechanisms.

CONCLUSIONS

Our knowledge in this area remains incomplete. Characterization of the mediators and receptors/ion channels on the sensory nerve terminals are required in order to facilitate the development of new pharmaceutical treatments for AP and CP.

Effects of systemic administration of a local anesthetic on pain in acute pancreatitis: a randomized clinical trial

OBJECTIVES

Intravenous local anesthetics may ameliorate pain and clinical course in patients with major abdominal surgery.

AIM

To investigate their effects in acute pancreatitis.

METHODS

Forty-six consecutive patients with acute pancreatitis randomly received intravenous procaine (2 g/24 h) or placebo for 72 hours in a double-blind fashion. Pain severity (visual analog scale, 0-100), on-demand pain medication (metamizole and/or buprenorphine), and the clinical course were monitored every 24 hours.

RESULTS

Data of 44 patients were subjected to intention-to-treat analysis. Although there were no differences between groups before treatment, procaine treatment was associated with a stronger decrease in pain compared with placebo (median visual analog scale decrement, -62 vs -39, P = 0.025). Moreover, there was a greater proportion of patients with adequate (≥ 67%) pain reduction (75% vs 43%, P = 0.018), less use of additional analgesics (P = 0.042), and overall analgesic superiority (P = 0.015). Compared with placebo, the proportion of patients hospitalized after 2 weeks was reduced by 80% after procaine treatment (P = 0.012).

CONCLUSIONS

These findings support the hypothesis that systemic administration of local anesthetics might improve pain and accelerate clinical recovery in acute pancreatitis.

NSAIDs and Acute Pancreatitis: A Systematic Review

The resulting pain is the main symptom of acute pancreatitis and it should be alleviated as soon as possible. NSAIDs are the first line therapy for pain and they are generally administered to acute pancreatitis patients upon admission to the hospital. In addition, these drugs have also been used to prevent post-endoscopic cholangiopancreatography (ERCP) acute pancreatitis. On the other hand, there are several reports indicating that NSAIDs may be the actual cause of acute pancreatitis. We carried out a literature search on PubMed/MEDLINE; all full text papers published in from January 1966 to November 2009 on the use of NSAIDs in acute pancreatitis were collected; the literature search was also supplemented by a review of the bibliographies of the papers evaluated. Thus, in this article, we will systematically review the current literature in order to better illustrate the role of NSAIDs in acute pancreatitis, in particular: i) NSAIDs as a cause of acute pancreatitis; ii) their use to prevent post-retrograde ERCP pancreatitis and iii) their efficacy for pain relief in the acute illness of the pancreas.

Fundamental and intensive care of acute pancreatitis

Patients who have been diagnosed as having acute pancreatitis should be, on principle, hospitalized. Crucial fundamental management is required soon after a diagnosis of acute pancreatitis has been made and includes monitoring of the conscious state, the respiratory and cardiovascular system, the urinary output, adequate fluid replacement and pain control. Along with such management, etiologic diagnosis and severity assessment should be conducted. Patients with a diagnosis of severe acute pancreatitis should be transferred to a medical facility where intensive respiratory and cardiovascular management as well as interventional treatment, blood purification therapy and nutritional support are available. The disease condition in acute pancreatitis changes every moment and even symptoms that are mild at the time of diagnosis may become severe later. Therefore, severity assessment should be conducted repeatedly at least within 48 h following diagnosis. An adequate dose of fluid replacement is essential to stabilize cardiovascular dynamics and the dose should be adjusted while assessing circulatory dynamics constantly. A large dose of fluid replacement is usually required in patients with severe acute pancreatitis. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with severe acute pancreatitis. Although the efficacy of intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional continuous regional arterial infusion and blood purification therapy.

Effect of four medications associated with gastrointestinal motility on Oddi sphincter in the rabbit

AIM

Modulatory drugs of gastrointestinal (GI) motility are a possibility for use to relieve the main clinical presentation of sphincter of Oddi (SO) dysfunctions which are not easily distinguished from those occurring in high prevalence functional GI disorders. The aim of this study was to investigate the effects of GI motility modulators including pinaverium, domperidone, trimebutine, and tegaserod on the contractile activity of SO stimulated by carbachol in the rabbit.

METHODS

The contraction responses precontracted by carbachol (0.1 microM) of in vitro rabbit SO rings were evaluated before and after the addition of a series concentration (10(-13) to 10(-3)M) of pinaverium, domperidone, trimebutine, and tegaserod.

RESULTS

Pinaverium induced a concentration-dependent relaxation of isolated SO rings (10(-13) vs. 10(-7) vs. 10(-3)M = 16.6 +/- 4.8 vs. 47.1 +/- 5.5 vs. 81.2 +/- 6.2%, p < 0.001 by ANOVA) precontracted with carbachol (0.1 microM). Tegaserod did not significantly effect (10(-13) vs. 10(-7) vs. 10(-3)M = 2.3 +/- 2.2 vs. 6.7+/- 2.1 vs. 10.1 +/- 2.3%, p > 0.05 by ANOVA) SO motility, but domperidone seemed to stimulate SO contractions (10(-12) vs. 10(-7) vs. 10(-3)M = -2.2 +/- 1.5 vs. -13.9 +/- 2.0 vs. -21.0 +/- 2.7%, p < 0.05 by ANOVA). At low doses (10(-13) to 10(-7)M), trimebutine stimulated SO contraction (-8.7 +/- 1.4 vs. -9.3 +/- 2.0%); however, high doses (10(-6) to 10(-3)M) of trimebutine inhibited SO motility (-5.9 +/- 1.7 vs. 14.5 +/- 2.0%, p < 0.05 by ANOVA).

CONCLUSION

Pinaverium totally inhibits contractions induced by carbachol and tegaserod has no effect on carbachol-induced contractions. Domperidone stimulates contractions induced by carbachol. Trimebutine could either stimulate or inhibit SO contractions depending on its dosage.