Drug-induced acute pancreatitis: underdiagnosis and overdiagnosis

Acute pancreatitis associated with pembrolizumab-induced hypertriglyceridemia

INTRODUCTION

Acute pancreatitis (AP) following drug-induced hypertriglyceridemia is a rare clinical phenomenon. Immune checkpoint inhibitors have revolutionized treatment for a variety of solid organ and hematological malignancies. Pembrolizumab is a programmed cell death receptor-1 (PD-1) inhibitor that has shown promising responses in many advanced cancers. However, a constellation of immune-related adverse events has also been described. There are reports of pembrolizumab-induced hypertriglyceridemia, but AP as a result of this side effect remains an exceedingly rare clinical sequela.

CASE REPORT

We delineate a case of a patient with stage IVB non-small-cell lung cancer who developed progressive abdominal pain and nausea following administration of pembrolizumab for four months. Laboratory studies revealed increased serum lipase and triglyceride levels at 12,562 IU/L and 16,901 mg/dL, respectively. The diagnosis of AP was made based on the revised Atlanta classification criteria. After ruling out alternative causes, pembrolizumab-induced hypertriglyceridemia was considered the likely etiology of AP.

MANAGEMENT AND OUTCOME

The patient was transferred to the medical intensive care unit for close monitoring. Treatment was initiated with intravenous fluids, pain medications, and an insulin infusion. However, her hypertriglyceridemia levels remained persistently elevated, necessitating therapeutic apheresis. She recovered well with no complications after triglyceride apheresis.

DISCUSSION

AP following pembrolizumab-associated hypertriglyceridemia remains a rare clinicopathologic entity. Given the widespread clinical use of immune checkpoint inhibitors, knowledge of such rare adverse events is crucial. Evaluation of serum triglyceride levels before and after initiating pembrolizumab therapy may be mandated, especially in patients with metabolic comorbidities.

Drug-Induced Acute Pancreatitis: A Real-World Pharmacovigilance Study Using the FDA Adverse Event Reporting System Database

Timely identification and discontinuation of culprit-drug is the cornerstone of clinical management of drug-induced acute pancreatitis (AP), but the comprehensive landscape of AP culprit-drugs is still lacking. To provide the current overview of AP culprit-drugs to guide clinical practice, we reviewed the adverse event (AE) reports associated with AP in the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database from 2004 to 2022, and summarized a potential AP culprit-drug list and its corresponding AE report quantity proportion. The disproportionality analysis was used to detect adverse drug reaction (ADR) signals for each drug in the drug list, and the ADR signal distribution was integrated to show the risk characteristic of drugs according to the ADR signal detection results. In the FAERS database, a total of 62,206 AE reports were AP-related, in which 1,175 drugs were reported as culprit-drug. On the whole, metformin was the drug with the greatest number of AE reports, followed by quetiapine, liraglutide, exenatide, and sitagliptin. Drugs used in diabetes was the drug class with the greatest number of AE reports, followed by immunosuppressants, psycholeptics, drugs for acid-related disorders, and analgesics. In disproportionality analysis, 595 drugs showed potential AP risk, whereas 580 drugs did not show any positive ADR signal. According to the positive-negative distribution of the ADR signal for drug classes, the drug class with the greatest number of positive drugs was antineoplastic agents. In this study, we provided the current comprehensive landscape of AP culprit-drugs from the pharmacovigilance perspective, which can provide reference information for clinical practice.

Case Report: Brentuximab Vedotin Associated Acute Pancreatitis in a Pediatric Hodgkin Lymphoma Patient: Case Report and Literature Review

Brentuximab vedotin is a conjugate drug used mainly in Hodgkin lymphoma, systemic and primary cutaneous anaplastic large cell lymphomas, and CD30-expressing peripheral T-cell lymphoma. We report a unique case of acute pancreatitis associated with brentuximab vedotin in a 17-year-old male patient suffering from classical Hodgkin lymphoma. Diagnosed in 2020, the patient was classified to an intermediate therapeutic group and disease’s grade was IIIAE. The patient was treated with brentuximab vedotin and bendamustine in the third line. Two weeks after the drug administration, the patient developed acute epigastric pain. Laboratory and radiological findings confirmed the clinical suspicion of acute pancreatitis that was managed with opioid pain medications, meropenem, parenteral nutrition, ondansetron and omeprazole. This is the first case report of brentuximab vedotin-associated acute pancreatitis in the pediatric patient reported in the literature to the best of our knowledge.

Severe necrotizing pancreatitis immediately after non-abdominal surgery under general anesthesia with propofol

Postoperative pancreatitis is a relatively rare disease and is poorly recognized. Herein, we present a case of necrotizing pancreatitis that developed immediately after non-abdominal surgery under general anesthesia. In this report, 4 h after thyroidectomy under general anesthesia using propofol, the patient developed upper abdominal pain and was diagnosed with severe acute pancreatitis with extensive pancreatic necrosis. Immediately after the diagnosis, the patient received appropriate treatment, and acute pancreatitis was improved. Subsequently, the patient has the formation of non-infectious giant walled-off necrosis and remained in good condition without additional treatment for 1.5 years after pancreatitis onset. In this case report, our detailed causative search suggested that propofol administration could be the cause of this pancreatitis. Propofol-induced pancreatitis is extremely rare but develops often severely, resulting in fatality. In this case, the patient developed severe acute pancreatitis within a very short time after surgery but was able to survive by immediate intervention of treatment. We suggest that clinicians should consider acute pancreatitis as a life-threatening adverse event under general anesthesia with propofol and perform thorough postoperative management.

The effect of medications associated with drug-induced pancreatitis on pancreatic cancer risk: A nested case-control study of routine Scottish data

BACKGROUND

Inflammation plays a role in pancreatic cancer. Many medications cause pancreatic inflammation, with some leading to a diagnosis of drug-induced pancreatitis (DIP), but few studies have examined these medications and pancreatic cancer risk. We therefore investigated the associations between pancreatic cancer risk and commonly-prescribed medicines for which there is strongest evidence of DIP.

METHODS

A nested case-control study was undertaken using the Primary Care Clinical Informatics Unit Research database containing general practice (GP) records from Scotland. Pancreatic cancer cases, diagnosed between 1999 and 2011, were identified and matched with up to five controls (based on age, gender, GP practice and date of registration). Medicines in the highest category of evidence for DIP, based on a recent systematic review, and used by more than 2 % of controls were identified. Odds ratios (OR) and 95 % confidence intervals (CI) for associations with pancreatic cancer were calculated using conditional logistic regression after adjusting for comorbidities.

RESULTS

There were 1,069 cases and 4,729 controls. Thirteen medicines in the highest category of evidence for DIP were investigated. There was little evidence of an association between any of these medications and pancreatic cancer risk apart from metronidazole (adjusted OR 1.69, 95 % CI 1.18, 2.41) and ranitidine (adjusted OR 1.37, 95 %CI 1.10, 1.70). However, no definitive exposure-response relationships between these medicines and cancer risk were observed.

CONCLUSIONS

There is little evidence that commonly-prescribed medicines associated with inflammation of the pancreas are also associated with pancreatic cancer. These findings should provide reassurance to patients and prescribing clinicians.

A case report: acute pancreatitis associated with tacrolimus in kidney transplantation

Background

Tacrolimus has been widely used for immunosuppressive therapy in solid organ transplantation (SOT) and allo-geneic stem cell transplantation (allo-SCT) over the past 2 decades. Pancreatitis caused by tacrolimus was rarely reported in kidney transplantation previously.

Case presentation

Here we presented a case of a 45-year-old male who underwent kidney transplantation and received immunosuppressive therapy of tacrolimus, on day + 67 after transplantation he developed acute pancreatitis with extremely high blood concentration of tacrolimus. We excluded other possible causes and speculated tacrolimus was the probable inducer of pancreatitis. After tacrolimus was discontinued and alternated with cyclosporine, he gradually recovered and was discharged home with no relapse.

Conclusion

Tacrolimus can be a probable cause of pancreatitis after kidney transplantation. We recommended clinicians to be aware of the possibility of tacrolimus-induced pancreatitis during tacrolimus treatment.

Etanercept - A culprit agent in acute pancreatitis?

Drugs are responsible for 3%-5% of acute pancreatitis cases. There are a lot of medications that are known to cause acute pancreatitis, however only one case has been reported so far on Etanercept.

This is a case about 62-year old female with history of Rheumatoid arthritis (RA) was started on Etanercept to control her severe RA symptoms. Three weeks later, she presented with abdominal pain, nausea, vomiting and found to have acute pancreatitis based on clinical symptoms and elevated pancreatic enzymes. A thorough workup for the cause of pancreatitis was done and all were unrevealing. There was no history of alcohol use, abdominal trauma or any gastroenterology procedures. Ultrasound and CT abdomen ruled out hepatobiliary abnormalities. Lipid profile and electrolytes including calcium were also found to be normal. As all the workup was unremarkable, it was thought that drug-induced acute pancreatitis was likely the case. Etanercept was the only medication that was started recently, which made it the likely culprit and therefore it was stopped. Patient continued to improve and was discharged after medical stabilization. Her rheumatologist started her on Abatacept and she has remained symptom-free since then.

Our case is interesting as it is the second case of etanercept induced acute pancreatitis. Furthermore, recent animal trials have demonstrated that etanercept potentially has a protective and/or therapeutic role in acute pancreatitis. However, no human studies regarding this topic have been performed. Due to limited data, a clear explanation behind these paradoxical actions of etanercept is still lacking.

Acute pancreatitis associated with intravenous administration of propofol: evaluation of causality in a systematic review of the literature

Acute pancreatitis (AP) associated with intravenous administration of propofol has been described with unknown causal relation. We therefore assessed this causality in a systematic review. Multiple databases were searched on 16 August 2017; studies were appraised and selected by two reviewers based on a priori criteria. Propofol causality was evaluated with the Naranjo scale and Badalov classification. We identified 18 studies from 11 countries with a total of 21 patients, and the majority had adequate methodological quality. The median age was 35 years (range, 4-77) and 10 (48%) were males. Overall, propofol was administrated in 8 patients as sedative along with induction/maintenance of anesthesia in 13 patients; median dose was 200 mg, with intermediate latency (1-30 days) in 14 (67%). Serum triglycerides were >1000 mg/dL in four patients. Severe AP was observed in four patients (19%). AP recurrence occurred in one out of two patients who underwent rechallenge. Mortality related to AP was 3/21(14%). Propofol was the probable cause of AP according to the Naranjo scale in 19 patients (89%). Propofol-induced AP has a probable causal relation and evidence supports Badalov class Ib. Hypertriglyceridemia is not the only mechanism by which propofol illicit AP. Propofol-induced AP was severe in 19% of patients with a mortality rate related to AP of 14%. Future research is needed to delineate whether this risk is higher if combined with other procedures that portend inherent risk of pancreatitis such as endoscopic retrograde cholangiopancreatography.

[Drug-induced acute pancreatitis: about 10 cases]

Drug-induced acute pancreatitis (AP) accounts for approximately 2% of acute pancreatitis. Its incidence is increasing, with more than 260 incriminated drugs. However, very few cases have been described in the literature due to accountability problem. We report our experience with 10 cases whose data were collected over a period of 7 years. Clinical presentation of AP was often equivocal. Ranson's score ranged from 0 to 5. We recorded 5 cases of edematous pancreatitis and 5 cases of necro-bleeding pancreatitis. These pancreatitis were often successfully treated without recurrence after discontinuation of the incriminated drug.

Acute pancreatitis induced by etoposide-lobaplatin combination chemotherapy used for the treatment of lung cancer: A case report and literature review

RATIONALE

Drug-induced pancreatitis (DIP) is a rare type of pancreatitis that is not usually observed in the clinical practice. It is generally difficult to distinguish from acute pancreatitis (AP) induced by other causes.

PATIENT CONCERNS

Here, we report a 62-year-old Chinese female patient with "small cell lung cancer" as the initial presentation. Because the patient could not bear the surgical treatment, the chemotherapy composed of lobaplatin and etoposide was performed. Three days later, the patient displayed sudden abdominal pain, distension, nausea, and vomiting without obvious inducements. Laboratory tests showed that the levels of serum and urine amylase were enhanced; abdominal computed tomography (CT) result showed the enlargement of the pancreas, peripancreatic effusion, and a rough edge, which suggested the diagnosis of AP. The patient had no history of biliary tract disease, alcoholism, binge overeating, hyperlipidemia, and hereditary pancreatitis.

DIAGNOSES

The patient was diagnosed with DIP.

INTERVENTIONS

The chemotherapy was stopped at once and we performed fluid resuscitation, pain alleviation, prophylactic antibiotics, and nutritional support, etc on the patient. Later, the patient's clinical symptoms were obviously relieved, and she recovered successfully.

OUTCOMES

The chemotherapy was continued, but later, the patient showed abdominal pain, distension, nausea, and vomiting again. The levels of serum amylase and urine amylase were enhanced again. Further imaging examination strongly indicated the recurrence of AP.

LESSONS

We should raise awareness of the clinicians regarding DIP, thereby enabling its timely diagnosis and accurate treatment, as well as promoting the rational and safe use of drugs.

Acute pancreatitis secondary to ciprofloxacin therapy in patients with infectious colitis

BACKGROUND/AIMS

Ciprofloxacin is considered to be a safe and effective treatment for acute infectious colitis. However, this drug may cause drug-induced pancreatitis, albeit rarely.

METHODS

From March 2007 to February 2012, we studied 227 patients who were hospitalized for infectious colitis at St. Mary's Hospital. All of the patients received ciprofloxacin therapy for the treatment of infectious colitis. We observed a few cases of rare adverse events, including ciprofloxacin-induced acute pancreatitis diagnosed based on the Naranjo algorithm.

RESULTS

During ciprofloxacin therapy, seven of 227 patients (3.1%) developed rare pancreatitis as defined by the Naranjo algorithm; pancreatic enzyme activity was sporadically elevated with ciprofloxacin use. After ciprofloxacin administration, the average interval until the development of pancreatitis was 5.5 days (range, 4 to 7 days). On abdominal computed tomography, pancreatic swelling and homogenous enhancement was noted in three of seven patients. Complicating acute pancreatitis was gradually but completely resolved after cessation of ciprofloxacin administration. The mean recovery time was 11.3 days (range, 8 to 15 days).

CONCLUSIONS

We observed that ciprofloxacin-induced pancreatitis may occur with an incidence of approximately 3%. Ciprofloxacin-induced pancreatitis presents a short latency, suggesting an idiosyncratic hypersensitivity reaction. Practitioners should be aware that drug-induced pancreatitis can occur during ciprofloxacin therapy.

Drug induced acute pancreatitis: Does it exist?

As the incidence of acute pancreatitis continues to rise, establishing the etiology in order to prevent recurrence is important. Although the etiology of acute pancreatitis is not difficult in the majority of patients, almost a quarter of patients are initially labeled as having idiopathic acute pancreatitis. When confronted with a patient with acute pancreatitis and no clear etiology defined as an absence alcoholism, gallstones (ultrasound and/or MRI), a normal triglyceride level, and absence of tumor, it often appears reasonable to consider a drug as the cause of acute pancreatitis. Over 100 drugs have been implicated by case reports as causing acute pancreatitis. While some of these case reports are well written, many case reports represent poorly written experiences of the clinician simply implicating a drug without a careful evaluation. Over-reliance on case reports while ignoring randomized clinical trials and large pharmacoepidemiologic surveys has led to confusion about drug induced acute pancreatitis. This review will explain that drug induced acute pancreatitis does occur, but it is rare, and over diagnosis leads to misconceptions about the disease resulting in inappropriate patient care, increased litigation and a failure to address the true entity: idiopathic acute pancreatitis.

Evaluation of miR-216a and miR-217 as potential biomarkers of acute pancreatic injury in rats and mice

Mild injury of the exocrine pancreas is often asymptomatic and can be under- or mis-diagnosed. The pancreas-enriched microRNAs miR-216a and miR-217 were evaluated as potential serum biomarkers of exocrine pancreas injury in rodent models of acute pancreatitis induced by caerulein, l-arginine, and pancreatic duct ligation. Both microRNAs showed time- and dose- relevant responses to pancreatic injury and wider dynamic ranges of response than serum amylase or lipase. Pancreas-selective microRNAs were found to be relatively sensitive serum biomarkers of pancreatic injury in rodents with potentially greater specificity than the current standard assays.

Acute pancreatitis: a prospective study on incidence, etiology, and outcome

BACKGROUND AND AIMS

Prospective and population-based studies on the incidence of acute pancreatitis (AP) are lacking. Alcohol consumption has increased considerably in Iceland during the last decade. We aimed to determine the incidence, etiology, severity, and complications of AP and compare the results with a previous study on AP in Iceland.

METHODS

A prospective population-based study of patients diagnosed with AP at the National University Hospital of Iceland during 1 year (2010-2011). Information on symptoms, etiology, and complications was registered.

RESULTS

During the study period, 134 patients were diagnosed with AP, 78 men (58%), median age 57 years (interquartile range 42-71). Overall, 89/104 (86%) patients had their first attack of pancreatitis, yielding a crude incidence of 40/100 000 inhabitants/year. The major etiological groups were as follows: gallstones, 52 cases (42%); alcohol 29, (23%); postendoscopic retrograde cholangio-pancreatography in 12 (9.5%); medications in eight (6.3%); and idiopathic in 15 (12%). Alcohol was more often the cause in men (25 vs. 4, P<0.05) but the incidence of gallstone-induced pancreatitis was similar in men and women (26 vs. 27). Seven patients had severe complications, three had pancreatic necrosis, two had pseudocysts, and one developed renal failure. Another patient developed acute respiratory distress syndrome and was admitted to the ICU. No patient died of AP during the study period.

CONCLUSION

The incidence of AP has not increased significantly in Iceland in the last decade. Alcohol-induced pancreatitis has not increased proportionally despite increased alcohol consumption in Iceland. In a population-based setting, the vast majority of AP is of mild severity.

Acute pancreatitis and concomitant use of pancreatitis-associated drugs

OBJECTIVES

Drug-induced pancreatitis (DIP) is considered a relative rare disease entity, perhaps due to lack of recognition. The objective of this study was to evaluate the prevalence of pancreatitis-associated drugs in a Dutch cohort of patients admitted for acute pancreatitis (AP) and to identify the proportion AP possibly attributable to the use of drugs.

METHODS

This was a multicenter observational study (EARL study). Etiology, disease course, use of pancreatitis-associated drugs at hospital admittance, and discontinuation of these drugs were evaluated. Drugs were scored by means of an evidence-based DIP classification system.

RESULTS

The first documented hospital admissions of 168 patients were analyzed. In all, 70 out of 168 (41.6%; 95% confidence interval (CI): 34.5-49.2%) patients used pancreatitis-associated drugs at admission. In 26.2% (44/168; 95% CI: 20.1-33.3%) of cases, at least one class I pancreatitis-associated drug was used. Possibly DIP was present in 12.5% (21/168; 95% CI: 8.3-18.4%); in less than half of these patients (9/21 or 42.9%; 95% CI: 24.5-63.5%), the prescribed drugs were actually discontinued, with no recurrence of AP later on. Among the remaining 12 patients without discontinuation of their drugs use and in absence of an alternative etiologic cause of AP, 8 patients used a class I pancreatitis-associated drug, representing 4.8% (8/168, 95% CI: 2.4-9.1%) of the total study population.

CONCLUSIONS

In this series, a remarkably high percentage of patients who were admitted because of an attack of AP used pancreatitis-associated drugs. Physicians should be more aware of the possibility of DIP in patients with otherwise unexplained AP and act appropriately by discontinuation of the drug.