Drug-induced acute pancreatitis

Genetic Variability in the CPA1 Gene and Its Impact on Acute Pancreatitis Risk: New Insights from a Large-Scale Study

Acute pancreatitis (AP) is a common and potentially lethal disease. Over the last 10 years, AP has become one of the most important healthcare problems. On a global scale, the incidence has increased by 63% over the last 20 years. AP is usually caused by gallstones and excessive alcohol consumption and genetic factors play an important role in the development of inflammation. Recent studies involving the CPA1 mutations are ambiguous and dependent on the population studied. In this study, the variability of the CPA1 gene in patients with AP was analyzed. Genetic material was isolated from the blood of 301 patients with AP and 184 healthy individuals. Identification of the variants in exons 5, 6, 8, and 9 with introns was performed using molecular biology methods. Mutations were identified by comparison to the reference sequence (NM_001868.4). Statistical analysis included the identification of mutations correlating with the risk of AP, the etiology of inflammation, and family history. Several novel mutations in the CPA1 gene have been identified, along with a high degree of variability within the coding region of the carboxypeptidase gene. A correlation between mutations CPA1:c.1072 + 84del; c.987 + 57G>A and increased risk of developing AP was found. Two protective mutations, CPA1:c.625A>T, c.1072 + 94del, were identified. The CPA1 gene is characterized by high sequence variability and regions in which mutations lead to an increased risk of developing AP. Single or co-occurring mutations of the CPA1 gene can significantly affect the risk of developing AP.

Considering Adverse Effects of Common Antihypertensive Medications in the ED

PURPOSE OF REVIEW

To evaluate the adverse effects of common antihypertensive agents utilized or encountered in the Emergency Department.

RECENT FINDINGS

All categories of antihypertensive agents may manifest adverse effects, inclusive of adverse drug reactions (ADRs), drug-to-drug interactions, or accidental overdose. Adverse effects, and specifically ADRs, may be stratified into the organ systems affected, might require specific time-sensitive interventions, could pose particular risks to vulnerable populations, and may result in significant morbidity, and potential mortality. Adverse effects of common antihypertensive agents may be encountered in the ED, necessitating that ED systems of care are poised to prevent, recognize, and intervene when adverse effects arise.

Statin Therapy and Pancreatitis: A Multi-Institutional Retrospective Analysis

INTRODUCTION

 Acute pancreatitis is a serious condition that has numerous etiologies and often requires hospital admission due to its high mortality rates. Statins are used worldwide to reduce the risk of cardiovascular disease. Some studies have shown an association between long-term statin use and acute pancreatitis. However, other studies have shown no effect or even postulated a mild protective effect. Due to conflicting information in the medical literature, the relationship between statins and acute pancreatitis remains unclear. The current study uses the TriNetX global research database to further investigate the impact of statin use on the development of acute pancreatitis over a five-year period.

METHODS

 Two cohorts were created using the TriNetX global research database. One group consisted of patients not taking statins, while the other group included patients taking any statins. Patients in both groups were required to be between the ages of 40 and 75 and had normal low-density lipoprotein cholesterol (LDL) (≤200 mg/dl) and triglyceride (≤150 mg/dl) levels. Patients were matched for age, gender, race, and comorbidities. The statin group was then compared to the no-statin group and measured for the outcome of the incidence of acute pancreatitis and the frequency of episodes within the first five years of statin use. Patients who experienced any acute pancreatitis episode before starting statin therapy or before meeting inclusion criteria were excluded from the study.

RESULTS

 Patients on statin therapy were significantly more likely to develop acute pancreatitis compared to patients not taking statin therapy (risk ratio 1.332, 95% CI: 1.242-1.429, P<0.0001). However, the statin group had a lower mean number of pancreatitis episodes than the no-statin group (4.6 vs. 5.3, P=0.043).

CONCLUSION

 The results from this large global dataset support the previously established idea that prolonged use of statins is associated with an increased risk of pancreatitis. Clinicians should strongly consider statin-induced pancreatitis when other common etiologies have been ruled out.

Risk factors for drug-related acute pancreatitis: an analysis of the FDA adverse event reporting system (FAERS)

Objective: While several drugs have been linked to acute pancreatitis (AP), the AP-related risk of most drugs remains unclear. This study investigated the risk factors for drug-induced AP by analyzing a large dataset from the FDA Adverse Event Reporting System (FAERS). Methods: The reporting odds ratios (ROR) were used to assess the reports of drug-induced AP from the first quarter of 2004 to the second quarter of 2022. Single-factor, LASSO, and multi-factor regression analysis were performed to explore drug-related AP-related risk factors. Bonferroni correction was applied for the multiple comparisons performed. Results: A total of 264 drugs associated with AP, including antineoplastic drugs (35/264), antidiabetic drugs (28/264), antibacterial drugs (24/264), immunomodulatory drugs (11/264), antipsychotic drugs (6/264), and other drugs (160/264) were retrieved. Multi-factor analysis showed that males, age 41-54 years old, and 36 drugs, including Tigecycline, were risk factors for drug-related AP. The median time to drug-related AP onset was 31 days (interquartile range [IQR] 7-102 days) and about 75% of adverse events occurred within 100 days. Conclusion: These findings may help clinicians to identify drug-related AP at the early stage and can be used to inform future studies of drug-related AP pathogenesis.

Rates and predictors of 30-day hospital readmissions in adults for drug-induced acute pancreatitis: A retrospective study from the United States National Readmission Database

BACKGROUND AND AIM

Drug-induced acute pancreatitis (DIAP) linked to several medications is a diagnosis of exclusion and is associated with significant morbidity and mortality, contributing to the US healthcare cost burden. Existing studies on DIAP focus on the drug classes that can cause acute pancreatitis. Hence, our retrospective study aims to determine the rates and predictors for 30-day readmissions (30-DR) in patients with index hospitalization for DIAP.

METHODS

From the Nationwide Readmissions Database, we followed adults admitted for DIAP who were discharged alive for 30 days. During 30-DR, we evaluated the rates, predictors, and outcomes of DIAP.

RESULTS

Of the 4457 DIAP patients surviving at discharge, 12.5% were readmitted at 30 days. During readmissions, the predictors of 30-DR for DIAP were young age, the Charlson-Deyo Comorbidity Index of 2 and 3, protein-energy malnutrition, and dyslipidemia. During 30-DR, DIAP had a higher mortality rate (2.4% vs. 0.7%; P < 0.020), extended hospital stays (5.6 days vs. 4 days, 0.000), and higher hospital charges ($12 983.6 vs. $8 255.6; P 0.000).

CONCLUSIONS

DIAP has high 30-DR rates and poorer outcomes.

The Role of Endoplasmic Reticulum Stress in Cell Injury Induced by Methimazole on Pancreatic Cells

Purpose: Methimazole is an anti-thyroid agent, especially as main therapy option for Graves' disease in children and adults. Drug induced pancreatitis is one of the known adverse effect of methimazole mentioned in case reports. However, the detailed molecular mechanisms of methimazole-induced pancreatitis are still unclear. In this study, the aim is to investigate the adverse effect of methimazole on pancreas cell stress mechanism and apoptosis. Methods: Cytotoxicity was evaluated in human pancreas/duct (PANC-1) cell line. Total oxidant (TOS) and antioxidant status (TAS) for oxidative stress index, glutathione (GSH) level and endoplasmic reticulum (ER) stress biomarkers were evaluated by ELISA. Reactive oxygen species (ROS) levels and apoptosis were evaluated by flow-cytometer. Results: The 30% inhibition rate concentration (IC₃₀) value was determined as 53 mM in PANC1 cells. The exposure concentrations were in the range of 0-40 mM for 48 hours. Methimazole might induce cellular stress conditions. ROS production increases depending on concentration, and this increase shows parallelism with the increase in ER stress biomarkers such as TOS, ERN1 and CASPASE12. Conversely, there was no significant difference between control and exposure groups in terms of apoptosis. Conclusion: In conclusion, methimazole might have triggered the mechanisms of inflammation or autophagy in the pancreatic cells. However, there is still a need for in vitro and in vivo studies including other cellular parameters related to apoptosis.

Delayed-Onset Losartan-Induced Pancreatitis Secondary to an Overdose: A Case Report

Acute pancreatitis is defined as inflammation of the pancreas and is most commonly caused by gallstones and alcohol use. Less commonly, acute pancreatitis can be drug induced from medications that are divided into 5 subgroups (classes Ia-V). The subgroups are determined based on the cases reported, reaction with rechallenge and a consistent period of latency. We describe a case of a 34-year-old female who overdosed on losartan pills in a suicide attempt but developed symptoms of drug-induced acute pancreatitis nearly a week later without gallstones, alcohol involvement, or other drug toxicity.

Acute pancreatitis secondary to tamoxifen-associated hypertriglyceridemia: A clinical update

INTRODUCTION

Drug-induced pancreatitis has been increasingly recognized, but it is frequently encountered as an inconspicuous etiology. The underlying mechanisms of injury vary with different drugs. Tamoxifen is a frequently used anticancer drug that acts by selective modulation of the estrogen receptor in patients with breast cancer. Tamoxifen-induced hypertriglyceridemia is a relatively rare etiological factor for acute pancreatitis. However, acute pancreatitis secondary to this adverse effect remains an exceedingly important clinicopathologic entity.

CASE REPORT

We hereby delineate a rare case of acute pancreatitis secondary to hypertriglyceridemia in a patient who was on tamoxifen treatment for the past 3 years. Her serum lipase and triglyceride levels were markedly elevated at 14,285 IU/L and 20,344 mg/dL, respectively. The diagnosis was considered based on the findings of a standard diagnostic workup and exclusion of alternative causes of acute pancreatitis.

MANAGEMENT AND OUTCOME

The patient was instituted prompt treatment with intravenous insulin infusion and gemfibrozil. The clinical outcome was favorable with no complications. Tamoxifen was permanently discontinued and was replaced with letrozole.

DISCUSSION

This article illustrates that acute pancreatitis should be considered in the differential diagnoses of abdominal pain and elevated pancreatic enzymes in patients undergoing tamoxifen treatment. It also underscores the importance of pre- and post-tamoxifen lipid screening, especially in patients with a history of dyslipidemia and diabetes mellitus. It will facilitate an expedient detection of hypertriglyceridemia, potentially saving patients from associated morbidity and mortality.

Weight-centric treatment of depression and chronic pain

Background

Depression and chronic pain are two major chronic non-communicable diseases (CNCD). Considering the bidirectional relationship between obesity and CNCD, it is of the utmost importance to understand the effect of medications utilized to treat these diseases on body weight.

Methods

This is a clinical review on the effect of medications for depression and chronic pain on body weight. We searched PubMed, Scopus, MEDLINE, and Google Scholar databases for studies on the topic from January 1, 1950 to April 1, 2022 in English language. Additionally, we present expert opinions in the fields of obesity, depression and chronic pain, providing a weight-centric approach to treat depression and chronic pain.

Results

Several antidepressant and chronic pain medications are associated with weight gain. Selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, monoamine oxidases, mirtazapine and trazodone are common antidepressants that can increase body weight while bupropion is significantly associated with weight loss. Gabapentin and pregabalin are common chronic pain medications that are linked to weight gain. On the other hand, topiramate is associated with significant weight loss. Obesity, depression and chronic pain experts recommend avoiding medications that can increase body weight if another effective alternative is available.

Conclusion

By shifting prescribing practices toward a weight-conscious approach (i.e., switching from weight gain medications to weight loss/neutral), it is possible to mitigate the incidence of drug-induced weight gain.

Investigation of the potential association between the use of fluoxetine and occurrence of acute pancreatitis: a Danish register-based cohort study

Background

There is currently conflicting evidence of the association between the use of selective serotonin reuptake inhibitors (SSRIs) and acute pancreatitis. The SSRI fluoxetine has been suspected to be the driver of this serious outcome. Therefore, this study aims to investigate the potential association between fluoxetine use and the occurrence of acute pancreatitis.

Methods

We conducted a nationwide cohort study using Danish register-based data from 1996 to 2016. The exposed group were new users of fluoxetine (1-year washout). The control subjects were new users of citalopram or SSRIs, excluding fluoxetine. The outcome was an incident diagnosis of acute pancreatitis with a 5-year washout. We used an intention-to-treat approach following patients for a maximum of 6 months. Cox regression analyses were performed, estimating hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for age/sex, comorbidities and co-medications, using propensity score adjustment and matching.

Results

In the propensity score-matched analyses, 61 783 fluoxetine users were included. The incidence rates among users of fluoxetine and other SSRIs were 5.33 (3.05–8.66) and 5.36 (3.06–8.70) per 10 000 person-years, respectively. No increased risk of acute pancreatitis was identified following fluoxetine exposure compared with either citalopram [HR 1.00, 95% CI 0.50–2.00) or other SSRIs (0.76, 0.40–1.46).

Conclusions

Fluoxetine use was not associated with an increased risk of acute pancreatitis compared with citalopram or other SSRIs. The absolute risk of acute pancreatitis was low and did not vary between different SSRIs. Further research is needed to determine whether there is a class effect on the risk of acute pancreatitis.

Drug-induced acute pancreatitis in a bodybuilder: a case report

Background

Unregulated use of a variety of drugs and supplements by bodybuilders and athletes is common and can lead to severe adverse complications. Only a small proportion of acute pancreatitis cases are drug induced, and case reports are essential for identifying potential drug-related risks for pancreatitis. Here we present the first case report published of acute pancreatitis linked to recreational use of anabolic–androgenic steroids, subcutaneous growth hormone, and clenbuterol in a previously healthy male after excluding all other causes of pancreatitis.

Case presentation

A 31-year-old Arab male bodybuilder presented with acute abdominal pain associated with nausea and sharp pain radiating to the back. The patient was not using tobacco or alcohol but was using multiple drugs related to bodybuilding, including anabolic–androgenic steroids, subcutaneous growth hormone, clenbuterol, and multiple vitamin supplements. Laboratory studies revealed a normal white blood cell count, elevated C-reactive protein, minimally elevated aspartate aminotransferase and total bilirubin with normal remaining liver tests, and elevated amylase and lipase. The patient had no hypertriglyceridemia or hypercalcemia, and had had no recent infections, abdominal procedures, trauma, or scorpion exposure. Imaging and laboratory investigations were negative for biliary disease and IgG4 disease. Abdominal computed tomography revealed hepatomegaly and diffuse thickening and edema of the body and tail of the pancreas with peripancreatic fat stranding. An abdominal ultrasound showed slight hepatomegaly with no evidence of cholelithiasis. Genetic testing for hereditary pancreatitis-related mutations was negative. A diagnosis of drug-induced acute pancreatitis was made, and he was treated with aggressive intravenous hydration and pain management. The patient has avoided further use of these drugs and supplements and had no further episodes of pancreatitis during 1 year of follow-up.

Conclusions

This case describes a patient with drug-induced acute pancreatitis after the intake of anabolic–androgenic steroids, subcutaneous growth hormone, and clenbuterol, where all other common causes of acute pancreatitis were excluded. Clinicians should be alert to the possibility of drug-induced acute pancreatitis occurring in bodybuilders and athletes using similar drug combinations.

Repaglinide-Induced Acute Pancreatitis

Acute pancreatitis is a common reason for hospitalization in the United States and can have a high degree of morbidity and mortality if not treated appropriately. Establishing the diagnosis and following guideline-directed medical therapy are both important. In the Western world, the most common causes include acute alcohol overuse, hypertriglyceridemia, gallstone pancreatitis, post-instrumentation including endoscopic cholangiopancreatography, and medication side effects. Our team describes the case of an 84-year-old male that was found to have acute pancreatitis secondary to repaglinide, a commonly used medication for the management of diabetes mellitus. The diagnosis was made based on the imaging findings, physical examination, and the corresponding laboratory markers. The patient was also found to have a blood-alcohol level at baseline and triglyceride levels within normal range. The patient’s symptoms resolved with the cessation of repaglinide administration. Our team hopes to make the medical community more aware of the potential association between repaglinide and the potentially rapidly debilitating disease. 

Quantifying the Risk of Drug-Induced Pancreatitis With Angiotensin-Converting Enzyme Inhibitors and Statins Using a Large Electronic Medical Record Database

OBJECTIVES

Quantify the risk of drug-induced pancreatitis (DIP) from angiotensin-converting enzyme inhibitors (ACEis) and 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitors (statins).

METHODS

Retrospective cohort analysis using IBM Explorys (1999-2019), a pooled, deidentified clinical database of more than 63 million patients across the United States. Odds ratios were calculated to determine the risk of DIP from ACEi, statins, and both medications together. χ2 testing assessed the relationship between age, sex, ethnicity, insurance status, and mortality among patients with DIP from ACEi, statins, or both combined.

RESULTS

Acute pancreatitis (AP) was found in 280,740 patients. Odds ratios for ACEi, statins, and both combined were 6.12, 4.97, and 5.72, respectively. Thirty-eight percent of all-cause AP occurs in adults older than 65 years. Acute pancreatitis from ACEi and statins occurs in 49% and 56% of patients older than 65 years, respectively. Men and patients older than 65 years are at higher risk of DIP from ACEi and statins. Patients on Medicaid are at higher risk of DIP from statins, and Asian patients are at highest risk of DIP from ACEi.

CONCLUSIONS

We found that ACEi and statins increase the odds of DIP. Although ACEis and statins are critical medications for many patients, clinicians should consider using alternatives in patients with AP of unclear etiology.

Comparative First-Line Effectiveness and Safety of ACE (Angiotensin-Converting Enzyme) Inhibitors and Angiotensin Receptor Blockers: A Multinational Cohort Study

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

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

ACVIM consensus statement on pancreatitis in cats

Background

Pancreatitis in cats, although commonly diagnosed, still presents many diagnostic and management challenges.

Objective

To summarize the current literature as it relates to etiology, pathogenesis, diagnosis, and management of pancreatitis in cats and to arrive at clinically relevant suggestions for veterinary clinicians that are based on evidence, and where such evidence is lacking, based on consensus of experts in the field.

Animals

None.

Methods

A panel of 8 experts in the field (5 internists, 1 radiologist, 1 clinical pathologist, and 1 anatomic pathologist), with support from a librarian, was formed to assess and summarize evidence in the peer reviewed literature and complement it with consensus clinical recommendations.

Results

There was little literature on the etiology and pathogenesis of spontaneous pancreatitis in cats, but there was much in the literature about the disease in humans, along with some experimental evidence in cats and nonfeline species. Most evidence was in the area of diagnosis of pancreatitis in cats, which was summarized carefully. In contrast, there was little evidence on the management of pancreatitis in cats.

Conclusions and Clinical Importance

Pancreatitis is amenable to antemortem diagnosis by integrating all clinical and diagnostic information available, and recognizing that acute pancreatitis is far easier to diagnose than chronic pancreatitis. Although both forms of pancreatitis can be managed successfully in many cats, management measures are far less clearly defined for chronic pancreatitis.

Drug-induced acute pancreatitis: Prevalence, Causative agents, and Outcomes

BACKGROUND

We sought to study the causative drugs, prevalence and outcomes of drug-induced acute pancreatitis (DIAP).

METHODS

Retrospective study of DIAP patients at a tertiary teaching hospital. The diagnosis and severity of pancreatitis were determined based on the Revised Atlanta Classification. The cases were further subclassified using the Badalov et al., 2008 classification, and Naranjo score to evaluate and determine the odds of drug-related adverse reaction as a causative factor for AP.

RESULTS

Out of 841 AP patients, a total of 31 patients (3.6%) with DIAP were included. The mean age was 52.9 years, 51.6% were male. The most common causative drugs are listed in Table 3. Most cases were mild in severity (87%), moderate AP occurred in 2 patients (6.5%) and severe AP in 2 patients (6.5%). 19.3% had systemic inflammatory response syndrome at presentation, but it persisted beyond 48 h in only 9.6%. 9.6% developed acute kidney injury. One patient with valproate induced DIAP had pancreatic necrosis, splenic vein thrombus, and sub occlusive superior mesenteric vein thrombus on abdominal imaging. Three patients had recurrent AP, and two (6.5%) of them eventually developed chronic pancreatitis. Notably, none of our patients developed complications such as shock, acute respiratory distress syndrome, bacteremia, or death. 1 patient had an acute peripancreatic fluid collection on initial imaging and another patient developed a pseudocyst on follow up imaging. None of them required drainage.

CONCLUSION

Our study showed a prevalence of DIAP of (3.6%) and hydrochlorothiazide, azathioprine, and doxycycline were the most common culprit drugs.

Ever-increasing diversity of drug-induced pancreatitis

With over 100000 hospital admissions per annum, acute pancreatitis remains the leading gastrointestinal cause of hospitalization in the United States and has far-reaching impact well beyond. It has become increasingly recognized that drug-induced pancreatitis (DIP), despite accounting for less than 3% of all cases, represents an important and growing though often inconspicuous cause of acute pancreatitis. Nevertheless, knowledge of DIP is often curtailed by the limited availability of evidence needed to implicate given agents, especially for non-prescription medications. Indeed, the majority of available data is derived from case reports, case series, or case control studies. Furthermore, the mechanism of injury and causality for many of these drugs remain elusive as a definitive correlation is generally not established (< 10% of cases). Several classification systems have been proposed, but no single system has been widely adopted, and periodic updates are required in light of ongoing pharmacologic expansion. Moreover, infrequently prescribed medications or those available over-the-counter (including herbal and other alternative remedies) are often overlooked as a potential culprit of acute pancreatitis. Herein, we review the ever-increasing diversity of DIP and the potential mechanisms of injury with the goal of raising awareness regarding the nature and magnitude of this entity. We believe this manuscript will aid in increasing both primary and secondary prevention of DIP, thus ultimately facilitating more expedient diagnosis and a decrease in DIP-related morbidity.

Non-steroidal Anti-inflammatory Drug-induced Acute Pancreatitis: A Case Report

Ibuprofen-induced acute pancreatitis, a diagnosis secondary to the use of non-steroidal anti-inflammatory drugs (NSAIDs), is an extremely rare occurrence. Common culprits, such as gallbladder obstruction, alcohol consumption, infection, direct trauma, and medication (i.e. NSAIDs), can be attributable to the majority of cases reported. This case report describes a patient with acute pancreatitis that developed due to a three-week course of daily ibuprofen use for chronic shoulder pain. Alternative causes of acute pancreatitis were excluded through the patient’s clinical history, laboratory findings, and diagnostic imaging. Although a rare risk factor, our aim is to further demonstrate that patients with chronic NSAIDs use can develop these complications and this should be considered among the differential diagnoses.

Etiology and Risk Factors of Acute and Chronic Pancreatitis

Based on the recognition of common etiological and genetic risk factors, acute and chronic pancreatitis are increasingly regarded as a continuum of the same disease, with a significant overlap of clinical manifestations and phenotypes but distinct morphological and imaging appearances. Recent population-based and cohort studies have found that tobacco smoke conveys a greater risk than immoderate alcohol consumption for the development of chronic pancreatitis, and hypertriglyceridemia has been identified as a risk factor for acute pancreatitis - even when plasma levels are only mildly elevated. Hereditary pancreatitis, in its autosomal dominant form, is associated with mutations in the cationic trypsinogen gene (PRSS1), whereas a number of germline variations in other genes have been found to represent risk factors for chronic as well as acute pancreatitis. For now, most of these involve the pancreatic digestive protease/antiprotease system. Oftentimes, affected patients are burdened with multiple or accumulating risk factors, and genetic traits when combined with environmental toxins compound the chance of developing the disease. Determining the underlying etiology of pancreatitis is worth the effort since formerly intractable varieties such as autoimmune pancreatitis are now becoming increasingly treatable, and subtype-specific therapeutic modalities may become available.

Tumor Necrosis Factor Alpha Inhibitor-Induced Acute Pancreatitis

Treatment of acute pancreatitis remains a challenge, with therapy focused on supportive care and treating the inciting etiology. Tumor necrosis factor-alpha (TNFα) inhibitors have shown promising results treating acute pancreatitis in animal models, but they have not been evaluated in human trials yet. A 25-year-old woman presented with ulcerative colitis. She was unresponsive to immunomodulators and developed acute pancreatitis shortly after initiation of a TNFα inhibitor. Her symptoms subsided after discontinuation of the medication, but reemerged when a different TNFα inhibitor was introduced to control her ulcerative colitis. Other potential etiologies were investigated and clinically excluded by laboratory and imaging studies.

Medication as a Cause of Acute Pancreatitis

BACKGROUND Acute pancreatitis is an inflammatory condition of the pancreas characterized clinically by epigastric abdominal pain and elevated levels of pancreatic enzymes in the blood. Drug-induced pancreatitis has recently gained more attention and as a result, physicians are screening more frequently for medications as a cause of acute pancreatitis. CASE REPORT We report the case of a 74-year-old man with a significant past medical history for coronary artery disease, sleep apnea, and gastroesophageal reflux disease who presented with epigastric pain radiating to the back. After a careful history was taken, it was found the patient recently started furosemide; therefore, a diagnosis of furosemide-induced acute pancreatitis was made. CONCLUSIONS Furosemide and other medications should be strongly considered in the differential diagnosis of patients presenting with acute pancreatitis.

Review of Infectious Etiology of Acute Pancreatitis

While gallstones and alcoholism are widely known to be the most common causative agents of acute pancreatitis, about 10% of cases are thought to be caused by infectious microorganisms. These microorganisms include viruses (e.g. mumps, Coxsackie B, and hepatitis), bacteria (e.g. Mycoplasma pneumoniae and leptospirosis), and parasites (e.g. Ascaris lumbricoides, Fasciola hepatica, and hydatid disease). Each organism causes acute pancreatitis through diverse mechanisms. The review is primarily conducted in an attempt to provide a better understanding of the possibility of acute pancreatitis presenting as a complication relating to these organisms, and the aim is to guide future diagnoses, management, and predictions of complications.

Use of incretin agents and risk of acute and chronic pancreatitis: A population-based cohort study

AIM

To determine the association between the use of incretin agents (dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists) for the treatment of type 2 diabetes mellitus (T2DM) and the risk of any, acute and chronic pancreatitis.

RESEARCH DESIGN AND METHODS

A population-based cohort study was conducted using data from the UK Clinical Practice Research Datalink (CPRD 2007-2012). A total of 182 428 adult patients with ≥1 non-insulin antidiabetic drug (NIAD) prescription were matched to control subjects without diabetes. Cox regression was used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of pancreatitis in incretin-users (N = 28 370) compared with controls and with other NIAD users. Adjustments were made for lifestyle, disease and drug history. In a sensitivity analysis, a new-user design was used.

RESULTS

Current incretin users had a 1.5-fold increased risk of any pancreatitis compared with NIAD users (adjusted HR 1.47, 95% CI 1.06-2.04). In incident current incretin users the risk of any and acute pancreatitis was increased 2.1- and 2.0-fold compared with NIAD users (adjusted HR 2.12, 95% CI 1.31-3.43 and adjusted HR 1.96, 95% CI 1.13-3.41), whereas there was no increased risk found for chronic pancreatitis.

CONCLUSIONS

Incretin use was associated with an increased risk of any pancreatitis. Moreover, risk of any and acute pancreatitis was higher when applying a new-user design. We were not able to detect an association with chronic pancreatitis, but the number in this subgroup was small.

Protective effect of Tribulus terrestris fruit extract on cerulein-induced acute pancreatitis in mice

OBJECTIVE

Antioxidant, anti-inflammatory, analgesic and antimicrobial activities of Tribulus terrestris (T. terrestris) could be helpful in the treatment of acute pancreatitis; thus, this study was designed to investigate the effects of T. terrestris on cerulein-induced acute pancreatitis in mice.

MATERIALS AND METHODS

Three doses (100, 200 and 400 mg/kg) of T. terrestris hydro-alcoholic extract were administered both orally (60 minutes before pancreatitis induction, p.o.) and intra-peritoneally (30 minutes before pancreatitis induction, i.p.) to different groups of mice (n=6). Pancreatitis was induced by five injections (i.p.) of cerulein 50μg/kg body weight with 1 hr intervals. Animals were euthanized 5 hr after the last injection of cerulein and tissue injures were assessed biochemically and pathologically.

RESULTS

T. terrestris extract 200 and 400mg/kg (p.o.) and T. terrestris extract 400 mg/kg (i.p.) reduced pancreatic tissue myeloperoxidase (MPO) activity and serum amylase and lipase levels and alleviated histological parameters.

CONCLUSION

These data suggest that T. terrestris hydro-alcoholic extract was effective in protecting against experimental acute pancreatitis and possibly the efficacy depends on dose and route of administration.

Tamoxifen-induced hypertriglyceridemia causing acute pancreatitis

Tamoxifen has both antagonistic and agonistic tissue-specific actions. It can have a paradoxical estrogenic effect on lipid metabolism resulting in elevated triglyceride and chylomicron levels. This can cause life-threatening complications like acute pancreatitis. To our knowledge, very few cases of tamoxifen-induced pancreatitis have been reported in the literature. We report a case of severe hypertriglyceridemia and acute pancreatitis following tamoxifen use. A 50-year-old diabetic lady was on tamoxifen (20mg/day) hormonal therapy for breast cancer. Within 3 months of starting therapy, she developed hypertriglyceridemia and acute pancreatitis. Laboratory values include: Serum amylase 778 IU/L, total cholesterol 785 mg/dL, triglycerides 4568 mg/dL and high-density lipoproteins (HDL) 12 mg/dL. Tamoxifen was substituted with letrozole and atorvastatin started. There was a prompt reversal of the adverse effects. Effects on lipid profile must be considered while initiating tamoxifen in predisposed individuals as the consequences are life threatening.

Use of incretin agents and risk of pancreatic cancer: a population-based cohort study

AIM

To investigate the association between the use of incretin agents and the risk of pancreatic cancer.

METHODS

A retrospective population-based cohort study, using data from the Clinical Practice Research Datalink, 2007-2012, was conducted. Patients (n = 182 428) with at least one non-insulin antidiabetic drug (NIAD) prescription and aged ≥18 years during data collection, were matched one-to-one to control patients without diabetes. Multivariable Cox proportional hazards models and a new user design were used to estimate the hazard ratio (HR) of pancreatic cancer in incretin users (n = 28 370) compared with control subjects without diabetes and other NIAD-treated patients. Time-dependent adjustments were made for age, sex, lifestyle, comorbidities and drug use.

RESULTS

The mean duration of follow-up was 4.1 years for incretin users. Current NIAD use was associated with a fourfold increased risk of pancreatic cancer [HR 4.28, 95% confidence interval (CI) 3.49-5.24]. This risk was almost doubled among current incretin users as compared with control subjects. Incretin use was not associated with pancreatic cancer when compared with control subjects with diabetes (HR 1.36, 95% CI 0.94-1.96); however, the 'new user' design did show an association between incretin use and pancreatic cancer when compared with control subjects with diabetes. In both cohorts with prevalent and incident users of antidiabetic drugs, the risk of pancreatic cancer almost doubled in those who had recently initiated incretin therapy (up to seven prescriptions), whereas this elevated risk dropped to baseline levels with prolonged use.

CONCLUSIONS

We found that incretin use was not associated with pancreatic cancer after adjustment for the severity of the underlying Type 2 Diabetes Mellitus (T2DM). The elevated risk of pancreatic cancer in those recently initiating incretin agents is likely to be caused by protopathic bias or other types of unknown distortion. The presence of considerable confounding by disease severity and the lack of a duration-of-use relationship do not support a causal explanation for the association between incretin agents and pancreatic cancer.

PAN's labyrinth: a multidisciplinary delayed diagnosis and patient's perspective

Polyarteritis nodosa (PAN) is a rare, severe form of vasculitis affecting medium-sized vessels. It manifests as a multisystem syndrome, and may be associated with hepatitis B virus-associated PAN (HBV-PAN) although the incidence of this is declining with better vaccination strategies and awareness of bloodborne virus screening. We report a case in which a patient displayed many classical features of the disease, occurring separately over a period of months and leading to contact with various medical specialties. Managing each symptom in isolation led to a number of misdiagnoses (including testicular cancer) and the patient experienced considerable psychological stress and morbidity as a result. The case was complicated by acute pancreatitis developing after an initial treatment response. This may have been iatrogenic (as a consequence of either entecavir or steroids) or secondary to PAN. For our patient, this led to a protracted clinical course but eventual complete resolution of both pathologies.

Interleukin 18 as an early marker or prognostic factor in acute pancreatitis

INTRODUCTION

Acute pancreatits (AP) still reqiures better diagnostic and therapeutic options to be introduced in order to decrease its morbidity and mortality. It appears that the assessment of serum levels of interleukin 18 (IL-18) and its correlation with C-reactive protein (CRP) may provide adequate prognostic value.

AIM

To measure serum concentrations of IL-18 and inflammation markers such as CRP in patients with AP during subsequent hospital stay days and to assess the role of IL-18 as an early AP marker and prognostic factor.

MATERIAL AND METHODS

Thirty-two patients aged 47 ±16.7 years were included into the study (17 males and 15 females), in whom AP was diagnosed based on ultrasound and computer aided tomography imaging and amylase. Serum amylase, CRP, and IL-18 levels were measured on the 1(st), 2(nd), 3(rd), and 5(th) days of hospital stay. All patients were scored "B" according to Balthazar and mild AP based on Ranson criteria. The control group consisted of 30 healthy volunteers aged 50.7 ±12.4 years (15 males and 15 females).

RESULTS

The average IL-18 serum level in the control group was 86.91 ±4.94 pg/ml. Mean IL-18 study group levels were 128.4 ±7.6 pg/ml on the 1(st), 112.0 ±4.4 pg/ml on the 3(rd), and 122.8 ±6.8 pg/ml on the 5(th) day of AP, and were significantly higher than those in the control group, accordingly: p < 0.001, p < 0.005, p < 0.001. A positive correlation between IL-18 and CRP serum concentrations was observed. A slight increase in correlation was observed as the days went by.

CONCLUSIONS

We concluded that the serum IL-18 level increases in the initial phase of AP, and it may be used as an inflammatory reaction marker in patients with AP, and it is correlated with CRP, which may indicate its prognostic role in AP.

A case of survival after chlorfenapyr intoxication with acute pancreatitis

Chlorfenapyr is a moderately hazardous insecticide. There have been previous reports of chlorfenapyr intoxication, but none have reported patient survival or an association with pancreatitis. A 61-year-old woman was brought to the emergency department with vomiting after ingesting 10 mL chlorfenapyr in a suicide attempt 1 hour before. The patient was treated with gastric lavage and activated charcoal, then transferred to the intensive care unit. Initial laboratory data were unremarkable except for elevated amylase/lipase levels (134/222 U/L), which were even higher 7 days later and remained elevated for 2 weeks. Abdominal computed tomography showed diffuse pancreatic swelling. The patient improved with conservative care and was discharged to home 19 days after admission. This is the first reported case of survival after chlorfenapyr intoxication. We recommend early aggressive management in the emergency department and close monitoring in the intensive care unit to detect and treat potentially fatal deterioration after chlorfenapyr intoxication.

Risk factors for pancreatitis in older women: the Iowa Women's Health Study

PURPOSE

Pancreatitis-an inflammation of pancreas-is a severe and costly disease. Although many risk factors for pancreatitis are known, many pancreatitis cases, especially in elderly women, are of unknown etiology.

METHODS

Risk factors for acute pancreatitis (AP) and chronic pancreatitis (CP) were assessed in a prospective cohort (n = 36,436 women, aged ≥ 65 years). Exposures were self-reported at baseline. Pancreatitis was ascertained by linkage to Medicare claims (1986-2004) categorized by a physician as follows: "AP", one AP episode (n = 511) or "CP", 2+ AP or 1+ CP episodes (n = 149).

RESULTS

Multivariable odds ratios (ORs) and 95% confidence intervals for AP and CP were calculated using multinomial logistic regression. Alcohol use was not associated with AP or CP. Heavy smoking (40+ vs. 0 pack-years) was associated with a twofold increased OR for CP. For body mass index greater than or equal to 30 versus less than 25 kg/m(2), the ORs were 1.35 (1.07-1.70) for AP (P trend = .009) and 0.59 (0.37-0.94) for CP (P trend = .01). ORs for AP and CP were increased for hormone replacement therapy use, heart disease, and hypertension. There were positive significant associations between protein and total fat intake for CP and AP.

CONCLUSIONS

We identified factors associated with AP and CP that may be specific to older women.

Drug-induced acute pancreatitis: a review

BACKGROUND

The majority of drug-induced pancreatitis cases are mild to moderate in severity, but severe and even fatal cases can occur. Management of drug-induced pancreatitis requires withdrawal of the offending agent and supportive care.

METHODS

This review focuses on differential diagnosis, clinical presentation, drug-mediated effects, treatments, and mechanisms of pancreatitis, with an emphasis on drug-induced pancreatitis.

RESULTS

Although only a minority of cases associated with acute pancreatitis are linked to drugs, clinical presentation and mechanisms of injury to the pancreas are not well understood by clinicians in terms of individual drug effects in the mediation or modulation of injury to the pancreas. In recent years, a large number of commonly prescribed medications has been linked to drug-induced pancreatitis pathogenesis. Although mechanisms are proposed, the exact cause of injury is either not well understood or controversial.

CONCLUSION

Future investigation into the mechanisms of pancreatitis and an appreciation by clinicians of the drugs commonly linked to the condition will help establish earlier diagnosis and quicker cessation of offending drugs in the treatment of drug-induced acute pancreatitis.

Pancreatitis potentially associated drugs as a risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis: a prospective cohort study

OBJECTIVES

The aim of this study was to assess the role of known risk factors and specifically evaluate the role of pancreatitis potentially associated drugs as potential risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS

This was a prospective, single-center cohort study conducted in a tertiary university hospital. All eligible ERCP procedures within a 16-month period were evaluated, and all interventions, patient characteristics, and medications used were documented. The association of potential risk factor with PEP was investigated with univariable analyses. Those statistically significant were entered in a multivariable regression model.

RESULTS

Three hundred eighteen ERCP procedures were studied. Post-ERCP pancreatitis occurred in 28 patients (8.8%). Twenty-three potential risk factors were studied in univariable analyses, and 3 of them were found to be nominally statistically significant. These 3 factors were independently associated with PEP in the multivariable model and included the use of pancreatitis potentially associated drugs, belonging to Badalov classes I or II, during the last month before ERCP (odds ratio [OR], 4.39; 95% confidence interval [CI], 1.70-5.47; P = 0.003), more than 1 guide-wire insertions in the pancreatic duct (OR, 5.00; 95% CI, 1.97-12.81; P = 0.001) and bile duct stone extraction (OR, 0.12; CI, 0.05-0.32; P < 0.001).

CONCLUSIONS

Pancreatitis potentially associated drugs used before ERCP seem to increase the risk for PEP.

Acute pancreatitis induced by methimazole in a patient with Graves' disease

BACKGROUND

Antithyroid drugs such as methimazole (MMI), the mainstay of pharmacologic therapy for Graves' disease, can provoke a variety of adverse effects. MMI-induced acute pancreatitis is very rare, being described in only a few patients and never after more than two exposures as reported here. Here, we report an 18-year-old girl with Graves' disease who developed acute pancreatitis each time she received MMI.

SUMMARY

The patient was an 18-year-old girl with Graves' disease who took MMI on four occasions. Each time she promptly developed similar features consisting of high fever and left upper quadrant abdominal pain. On three occasions, serum lipase and amylase values were measured. Serum lipase was elevated on all three occasions and serum amylase was elevated once. Features resolved after MMI was stopped. We considered these episodes to be most consistent with pancreatitis, and to be induced by MMI administration.

CONCLUSION

MMI-induced acute pancreatitis is rare and easily misdiagnosed. Based on very limited experience, it should resolve after MMI is stopped. The pathogenesis of MMI-induced pancreatitis is not known. Clinicians should be aware of this entity so that MMI is promptly stopped if the features described here develop after MMI is started, and measures are taken to avoid future MMI treatment.

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.

Acute pancreatitis with saw palmetto use: a case report

Introduction

Saw palmetto is a phytotherapeutic agent commercially marketed for the treatment of benign prostatic hyperplasia. Evidence suggests that saw palmetto is a safe product, and mild gastrointestinal adverse effects have been reported with its use. We report a case of acute pancreatitis, possibly secondary to the use of saw palmetto.

Case presentation

A 61-year-old Caucasian man with a history of benign prostatic hyperplasia and gastroesophageal reflux disease developed epigastric pain associated with nausea 36 hours prior to presentation. He denied drinking alcohol prior to the development of his symptoms. His home medications included saw palmetto, lansoprazole and multivitamins. Laboratory results revealed elevated lipase and amylase levels. An abdominal ultrasound demonstrated a nondilated common bile duct, without choledocholithiasis. Computed tomography of his abdomen showed the pancreatic tail with peripancreatic inflammatory changes, consistent with acute pancreatitis. Our patient's condition improved with intravenous fluids and pain management. On the fourth day of hospitalization his pancreatic enzymes were within normal limits: he was discharged home and advised to avoid taking saw palmetto.

Conclusion

It is our opinion that a relationship between saw palmetto and the onset of acute pancreatitis is plausible, and prescribers and users of saw palmetto should be alert to the possibility of such adverse reactions.

Atorvastatin-induced acute pancreatitis

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

Drug-induced acute pancreatitis related to medications commonly used in gastroenterology

BACKGROUND

With the growing number of pharmacological agents available nowadays, the gastrointestinal drug-induced side effects become more common than ever. However, drug-induced pancreatitis belongs to rather seldom reported adverse drug reactions, probably because of the difficulty in proving the relationship between an inflammation of the pancreas and the pharmacotherapy with a certain drug.

AIM

The aim of this review is to draw attention to an infrequent but real problem of drug-induced acute pancreatitis associated with medications commonly used in the treatment of gastrointestinal disorders.

METHODOLOGY

For the purpose of that the PubMed database was searched using the keywords "drug-induced pancreatitis", "drug-associated pancreatitis", "acute pancreatitis", "pancreatitis" in various combinations and relevant literature was reviewed.

RESULTS

A substantial number of drugs commonly prescribed for gastrointestinal disorders are known to cause acute pancreatitis. Case reports and review articles published so far draw attention to medications already known to cause drug-induced pancreatic damage as well as implicate new drugs. Generally, the etiopathological mechanisms involved in drug-induced pancreatitis remain unclear. It is difficult to establish or rule out definitely such unwanted event, especially in patients taking numerous medications prescribed for multiple comorbidities.

CONCLUSION

Pharmacological agents are among etiologic factors that should be considered in all patients presenting with signs and symptoms consistent with acute pancreatitis. The diagnosis of drug-induced AP is often difficult to established. Therefore a high index of suspicion and thorough drug history are crucial for making the final diagnosis.

Drug-induced acute liver failure and gastrointestinal complications

The objective of this article is to describe adverse drug events related to the liver and gastrointestinal tract in critically ill patients. PubMed and other resources were used to identify information related to drug-induced acute liver failure, gastrointestinal hypomotility, constipation, diarrhea, gastrointestinal bleeding, and pancreatitis in critically ill patients. This information was reviewed, and data regarding pathophysiology, common drug causes, and guidelines for prevention and management were collected and summarized. In cases in which data in critically ill patients were unavailable, data were extrapolated from other patient populations. Drug-induced acute liver failure can be caused by many drugs routinely used in the intensive care unit and may be associated with significant morbidity and mortality. Drug-related hypomotility and constipation and drug-related diarrhea are reported with many drugs, and these are common adverse drug events in critically ill patients that can substantially complicate the care of these patients. Drug-induced gastrointestinal bleeding and drug-induced pancreatitis occur less frequently, can range in disease severity, and can be associated with morbidity and mortality. Many drugs used in critically ill patients are associated with adverse drug events related to the liver and gastrointestinal tract. Critical care clinicians should be aware of common drug causes of drug-induced acute liver failure, gastrointestinal hypomotility, constipation, diarrhea, gastrointestinal bleeding, and pancreatitis, and should be familiar with the prevention and management of these diverse conditions.

A possible case of saw palmetto-induced pancreatitis

A 65-year-old male with a history of diabetes, hypertension, hyperlipidemia, gout, Barrett esophagitis, and chronic gastritis developed acute pancreatitis after taking one week of the herbal medicine, saw palmetto, for symptoms related to benign prostatic hyperplasia (BPH). Ultrasound and computed tomography ruled out cholelithiasis and obstruction, triglycerides were normal, and he had no recent infection or trauma. He had a history of occasional alcohol consumption, though there was no recent increased intake. The most likely cause of pancreatitis in this case was saw palmetto. Saw palmetto (Serenoa repens) is an herbal medication used primarily in the treatment of symptoms related to BPH. It has a high content of fatty acids and phytosterols which are thought to exert their effects by inhibiting the enzyme 5-alpha-reductase, thereby preventing the conversion of testosterone into dihydrotestosterone (DHT). It has been postulated that saw palmetto directly stimulates estrogenic receptors and inhibits progesterone receptors in the prostate tissue. A previous report implicated the estrogen/antiandrogen properties of saw palmetto as inducing hepatotoxicity in a patient. Additionally, it has also been postulated that stimulation of the estrogenic receptors may lead to increased triglyceride levels or induction of a hypercoagulable state that leads to pancreatic necrosis. Finally, inhibition of cyclooxygenase, a property of saw palmetto, may be linked to acute pancreatitis. Acute pancreatitis, a serious and sometimes fatal disorder may occur secondary to medications. Although the mechanism is not fully known, this is the second case of acute pancreatitis that has been documented secondary to the herbal medication saw palmetto. It is important for clinicians to obtain detailed medication histories, including over-the-counter and herbal medications, in order to prevent further complications from occurring.

Exenatide-induced acute pancreatitis

OBJECTIVE

To report acute pancreatitis in a patient with non-insulin-dependent diabetes mellitus (NIDDM) receiving exenatide and critically review previous reports.

METHODS

We describe clinical and laboratory data of a woman with probable exenatide-induced pancreatitis and apply the same criteria to previously published cases.

RESULTS

A 64-year-old, nonalcoholic woman with NIDDM presented with a 1-month history of epigastric pain beginning 2 days after starting exenatide. Serum lipase concentration was 2700 U/L (reference range, 114-320 U/L), and serum amylase concentration was 131 U/L (reference range, 30-110 U/L). Liver function test results, lipid profile, and serum creatinine concentration were normal. Abdominal computed tomography (CT) showed changes consistent with pancreatitis, and the gallbladder was absent. Exenatide was discontinued. Conservative therapy resulted in rapid resolution of symptoms, normal lipase concentration (151 U/L), and normal findings from CT of the pancreas 90 days later. The US Food and Drug Administration has reported 36 cases of presumed pancreatitis associated with exenatide. However, none of the selection criteria were specified, two-thirds of the patients did not have CT, and 90% had at least 1 other risk factor for acute pancreatitis. A single published case report of exenatide-induced pancreatitis contains no description of the pancreas on abdominal CT, does not mention alcohol use, and does not report normal lipase values.

CONCLUSIONS

This is the most thoroughly documented example of probable exenatide-induced pancreatitis. In any diabetic patient with acute pancreatitis, exenatide must be ruled out as the cause and its use discontinued.

Acute pancreatitis after nifedipine and acetaminophen poisoning — case report

The incidence of drug-induced pancreatitis is rare. There have been several reports of acute pancreatitis as a complication in acute poisoning with drugs or toxins. We present a case of a young woman with acute pancreatitis secondary to an overdose of nifedipine and acetaminophen in a suicide attempt. We excluded other causes of acute pancreatitis by clinical history, serum toxicology, serology, and abdominal imaging. The most likely underlying pathophysiological mechanism was ischemic injury of the pancreas secondary to severe collapse induced by nifedipine and possible acetaminophen-induced direct pancreatotoxicity. The pancreatitis resolved with treatment that included continuous veno-venous haemofiltration in an intensive care unit. Emergency and intensive care units should be aware of this unusual complication of such poisoning. To our knowledge, this is the first reported association between massive nifedipine overdose and acute pancreatitis.

Gastric varices with remarkable collateral veins in valpronic Acid-induced chronic pancreatitis

Valproic acid (VPA) is a commonly prescribed and approved treatment for epilepsy, including Angelman syndrome, throughout the world. However, the long-term administration of drugs like VPA is associated with the possible development of gastric varices and splenic obstruction as a result of chronic pancreatitis. Such cases can be difficult to treat using endoscopy or interventional radiology because of hemodynamic abnormalities; therefore, surgical treatment is often necessary.