Octreotide treatment in patients with necrotizing pancreatitis and pulmonary failure

The effect of thymosin α1 for prevention of infection in patients with severe acute pancreatitis

INTRODUCTION

Severe acute pancreatitis (SAP) is an acute inflammatory disease with prolonged clinical course, which is complicated by the presence of persistent organ failure and severe infection. Infection mainly occurs in the late phase of SAP and it is found to be the main cause of death. Therefore, developing strategies for the prevention of SAP-related infection has been a crucial approach to improve patients' outcomes. Due to remarkable immune-cells-regulating properties, thymosin α1 has been recognized as a promising immune therapy, especially in several infectious diseases. Recently, thymosin α1 has been given high expectations to exert clinical benefits in the prevention of SAP-related infection.

AREAS COVERED

The review of currently available strategies for SAP-related infection prevention and the use of thymosin α1 in SAP patients.

EXPERT OPINION

The current available strategies achieve limited success for preventing SAP-related infection. A possible explanation is that the trigger of infection, immunosuppression has not been concurrently resolved. The application of thymosin α1 in a clinical study showed a prophylactic effect against SAP-related infection. However, the use of thymosin α1 in SAP patients is still at an early stage of clinical investigation and requires high-quality and large sample size evidences.

Immunomodulatory therapies for acute pancreatitis

It is currently difficult for conventional treatments of acute pancreatitis (AP), which primarily consist of anti-inflammatory therapies, to prevent the progression of AP or to improve its outcome. This may be because the occurrence and progression of AP, which involves various inflammatory cells and cytokines, includes a series of complex immune events. Considering the complex immune system alterations during the course of AP, it is necessary to monitor the indicators related to immune cells and inflammatory mediators and to develop more individualized interventions for AP patients using immunomodulatory therapy. This review discusses the recent advances in immunomodulatory therapies. It has been suggested that overactive inflammatory responses should be inhibited and excessive immunosuppression should be avoided in the early stages of AP. The optimal duration of anti-inflammatory therapy may be shorter than previously expected (< 24 h), and appropriate immunostimulatory therapies should be administered during the period from the 3^rd d to the 14^th d in the course of AP. A combination therapy of anti-inflammatory and immune-stimulating drugs would hopefully constitute an alternative to anti-inflammatory drug monotherapy. Additionally, the detection of the genotypes of critical inflammatory mediators may be useful for screening populations of AP patients at high risk of severe infections to enable the administration of early interventions to improve their prognosis.

High-dose versus low-dose octreotide in the treatment of acute pancreatitis: a randomized controlled trial

To evaluate the therapeutic efficacy of high-dose octreotide in patients with predicted severe acute pancreatitis (SAP) or SAP, two hundred and thirty-six patients with predicted SAP and 136 patients with SAP were randomized into control, high-dose octreotide (High-O) and low-dose octreotide (Low-O) groups. In addition to the conventional managements administrated in control group, High-O group received an intravenous infusion of octreotide at 50 μg/h × 3d + 25 μg/h × 4d, and Low-O group received octreotide at 25 μg/h × 7d. The major primary outcomes included the numbers of predicted SAP patients which developed SAP after intervention and the number of patients with SAP amelioration. Secondary outcomes included APACHE II, SIRS scores, plasma levels of somatostatin (SST), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6). There were no significant differences between the control and Low-O groups in terms of prevention and treatment for SAP. The incidence of SAP in patients with predicted SAP who received High-O was significantly lower than the Low-O group: 37.5% vs. 59.8%, p=0.005. Compared with Low-O group, the number of SAP patients in the SAP arm in the High-O group was reduced by 29.8%. Plasma levels of SST in both predicted SAP and the SAP patients were efficiently recovered (from 132.71±31.40 pg/ml to 180.00±23.50 pg/ml, p<0.05) after high-dose octreotide supplementation, which concomitantly reduced TNF-α and IL-6 levels. High-dose octreotide administration within 48h after AP onset may efficiently reduce the risk of SAP developing and partly attenuate SAP through raising plasma SST to a normal level and decreasing IL-6 and TNF-α.

Current pharmacotherapeutic recommendations for acute pancreatitis

Disease severity in patients with acute pancreatitis varies from mild disease with minimal morbidity to severe disease in which a whole spectrum of local and systemic complications may occur. Infectious complications frequently arise, and pancreatic necrosis in particular is an important risk factor for mortality. Several strategies have been investigated to stop the progression of organ dysfunction, targeting different steps in the pathogenesis, but none of these have proved beneficial. In recent years, the widespread use of prophylactic antibiotics has also been in question, as one blinded study could not demonstrate an advantage. Better risk stratification methods should improve the design of future trials, so that only patients with a high probability of complications can be studied.

Evidence-based treatment of acute pancreatitis: a look at established paradigms

BACKGROUND

The management of acute pancreatitis (AP) is still based on speculative and unproven paradigms in many centers. Therefore, we performed an evidence-based analysis to assess the best available treatment.

METHODS

A comprehensive Medline and Cochrane Library search was performed evaluating the indication and timing of interventional and surgical approaches, and the value of aprotinin, lexipafant, gabexate mesylate, and octreotide treatment. Each study was ranked according to the evidence-based methodology of Sackett; whenever feasible, we performed new meta-analyses using the random-effects model. Recommendations were based on the available level of evidence (A=large randomized; B=small randomized; C=prospective trial).

RESULTS

None of the evaluated medical treatments is recommended (level A). Patients with AP should receive early enteral nutrition (level B). While mild biliary AP is best treated by primary cholecystectomy (level B), patients with severe biliary AP require emergency endoscopic papillotomy followed by interval cholecystectomy (level A). Patients with necrotizing AP should receive imipenem or meropenem prophylaxis to decrease the risk of infected necrosis and mortality (level A). Sterile necrosis per se is not an indication for surgery (level C), and not all patients with infected necrosis require immediate surgery (level B). In general, early necrosectomy should be avoided (level B), and single necrosectomy with postoperative lavage should be preferred over "open-packing" because of fewer complications with comparable mortality rates (level C).

CONCLUSIONS

While providing new insights into key aspects of AP management, this evidence-based analysis highlights the need for further clinical trials, particularly regarding the indications for antibiotic prophylaxis and surgery.

Gabexate mesilate and acute pancreatitis: an experience of evidence based drug information for improving rational drug use

INTRODUCTION

Gabexate mesylate is a drug marketed only in Italy and Japan and it is considered an essential drug in the treatment of acute pancreatitis. A periodic revision and evaluation of drug utilization in our hospital demonstrated that the dosages and indications of Gabexate mesilate (GM) did not follow those settled by the National Health System and by our Hospital Formulary. We therefore promoted and conducted a program of drug information and meetings with the physicians in order to improve the correct utilisation of GM and identify potential problems.

METHODS

GM prescriptions in 1999 were analysed for indications and dosages. Scheduled meetings with the medical staff were successively started in order to debate current therapies and treatments of acute pancreatitis using the criteria of evidence-based medicine (EBM). Follow-up was done in 2000, 2001 and 2002 to evaluate the efficacy of our intervention.

RESULTS

The hospital board and 20 physicians were involved in this program of evidence-based drug information. The follow-up and the monitoring of GM prescriptions showed a reduction in the utilisation of GM in the subsequent period.

CONCLUSIONS

GM is one of the most expensive drugs in our hospital, but its benefits are not very evident. Moreover, the international guidelines and literature ascribe to GM only a marginal role in the treatment of acute pancreatitis. Evidence-based medicine strengthens clinical experience with the evidence from the literature and underlines that essential drugs are used worldwide.

The effects of somatostatin and octreotide on experimental and human acute pancreatitis

The role of somatostatin and octreotide for AP has been studied for two decades, yet the data still remain inconclusive. The inconsistencies of the results of experimental studies and clinical trials may stem from the fact that the optimal therapeutic modality has not been determined. Furthermore, although they are similar in structure and physiologic activities, the mechanisms of action and effects of somatostatin and octreotide in AP may be different. Because the data are sparse, most reports, primarily those in the English literature, on the efficacy of somatostatin and octreotide in the management of AP were reviewed. Included are both nonrandomized and prospective, double-blind, clinical trials and studies on the effects of these agents on various experimental models of the disease. The results of the studies on somatostatin and octreotide are presented and discussed separately, with specific reference to the experimental and treatment details. The main focus of the review is the effect of subcutaneous and intravenous administration of octreotide. Analysis of the data suggests that somatostatin could not be recommended for AP and that the efficacy of subcutaneous administration of octreotide is also questionable. Theoretically, intravenous octreotide may be more appropriate for this condition, but recent results with this therapeutic method are limited and contradictory. Studies that would delineate the optimal therapeutical modality and the patient population most likely to respond to the treatment are prerequisite for large-scale clinical trials on the effects of octreotide on human pancreatitis.

Nutritional management in acute and chronic pancreatitis

Patients with severe pancreatitis, characterized by multiple organ failure and pancreatic necrosis on CT scan (identified by an Acute Physiology and Chronic Health Evaluation II score of > or = 10 with > or = 3 Ranson criteria), most likely require aggressive nutritional support. Use of the enteral route of feeding may help contain the hypermetabolic stress response, reduce morphologic change and atrophy of the gut, and theoretically decrease late complications of nosocomial infection and organ failure. Evidence that decreasing degrees of stimulation of the pancreas occur as the site of feeding descends in the gastrointestinal tract and evidence from perspective, randomized trials suggest that jejunal feeding appears at least as safe and well tolerated as total parenteral nutrition in acute pancreatitis.