Ketorolac and Predicted Severe Acute Pancreatitis: A Randomized, Controlled Clinical Trial

Contemporary Approach to Acute Pancreatitis in Emergency Medicine

Acute pancreatitis is a commonly encountered pathology in the emergency department. We presented a clinical review summarizing the contemporary emergency medicine approach to managing acute pancreatitis. Although the diagnostic criteria for acute pancreatitis are straightforward, it has many possible causes, several treatment options, and both short- and long-term sequelae. We discussed diagnostic, intervention, and disposition considerations relevant to emergency clinicians and considered risk assessment using available clinical decision tools. We also discussed changes to traditional treatments and ongoing investigational therapies, including steroids, monoclonal antibodies, and calcium release-activated calcium channel inhibitors.

Effect of selective COX-2 inhibitors and non-selective non-steroidal anti-inflammatory drugs on severity of acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

It's been suggested that non-steroidal anti-inflammatory drugs (NSAIDs) may reduce the inflammatory response and severity of acute pancreatitis (AP). In this systematic review and meta-analysis, we aimed to explore the impact of selective COX-2 and non-selective NSAIDs compared to non-NSAID options on the severity of AP.

METHODS

We searched MEDLINE, EMBASE, and Cochrane Central, from database inception through September 2023. We included RCTs and observational studies comparing NSAIDs with non-NSAID controls. The primary outcome was the development of severe acute pancreatitis (SAP) characterized by persistent organ failure lasting >48 h. Secondary outcomes included mortality, pancreatic necrosis, length of stay (LOS), pain relief, and requirement for rescue analgesia. Meta-analysis was conducted separately for selective COX-2 inhibitors and non-selective NSAIDs.

RESULTS

Eleven studies met eligibility criteria including 1830 patients with AP. Of 3 studies that used selective NSAIDs (1 RCT and 2 observational), COX-2 inhibitors significantly reduced SAP (OR = 0.38; 95 %CI 0.27-0.52; p < 0.001; I2 = 0 %), pancreatic necrosis (OR = 0.48; 95 %CI 0.29-0.78; p = 0.003; I2 = 0 %), LOS by 5.51 days (95 %CI -10.80 to -0.22; p = 0.04; I2 = 97 %), and rescue opioids (OR = 0.32; 95 %CI 0.24-0.45; p < 0.001; I2 = 0 %). However, the certainty of the evidence was graded as low to very low using GRADE methodology. There was no significant effect of COX-2 inhibitors on mortality. Of 8 studies (all RCTs) that compared non-selective NSAIDs and non-NSAIDs, there was no difference in clinical outcomes, pain relief, and need for rescue analgesia.

CONCLUSIONS

Selective COX-2 inhibitors potentially mitigate disease severity and shorten hospitalization in patients with AP, while non-selective NSAIDs lack this benefit. Confirmatory large-scale RCTs are warranted to validate these findings.

Safety, tolerability and therapeutic efficacy of anti-inflammatory drug pirfenidone in acute pancreatitis patients: Protocol for a randomized pilot clinical trial

BACKGROUND

Acute Pancreatitis (AP) is a formidable disease with significant morbidity, mortality and healthcare expenditure. There is an emergent need to develop therapeutic agents for this disease as there are no targeted therapies available. We have recently demonstrated that pirfenidone can significantly decrease the severity of AP in animal models. Based on our preclinical findings, we decided to conduct a pilot trial to evaluate the safety, tolerability and efficacy of pirfenidone in patients with AP.

METHODS

We have designed a multicenter, randomized, pilot clinical trial of 60 patients with blinded outcome assessment. All patients with AP, who present within 48 h of establishment of the diagnosis, will be screened for exclusion and inclusion criteria. Consenting patients will be randomized into pirfenidone or placebo within 48 h of the diagnosis of AP. The primary end points include decrease in PAN-PROMISE score after 72 h of initiation of drug, reduction in inflammatory markers, and development of serious adverse events. The secondary end points include changes in PAN-PROMISE score, discharge PASS score <60, development of composite outcome of new or worsening necrotizing pancreatitis on CT scan performed 5-7 days after admission, major infection or death, and readmissions and/or ER visits within 30 days and within 6 months after discharge.

STATUS

Currently enrolling (NCT05350371).

CONCLUSION

There is an urgent need to identify novel therapies for AP. This pilot clinical trial may become the basis of a larger study to analyze the efficacy of pirfenidone in patients with AP.