Published: 7 June 2019

Publications

Acute pancreatitis – Sometimes triggered by medicines

Prescriber Update 40(2): 30-31
June 2019

Key Messages

  • Medicines are a rare cause of acute pancreatitis.
  • If medicine-induced pancreatitis is suspected, withdrawal of the suspected medicine is usually effective.

Background

Acute pancreatitis (AP) is a major gastrointestinal cause of hospitalisation. The condition is commonly caused by gallstones or excessive alcohol use. AP is characterised by inflammation of the pancreas and elevated levels of pancreatic enzymes (amylase and lipase) in the blood. It is likely that very few AP cases are triggered by medicines – estimates range from 0.1 to 2% of cases of AP1. However, as the incidence of all-cause AP is high2, drug-induced pancreatitis (DIP) is still an important consideration.

Drug-induced pancreatitis

DIP does not have any unique clinical features to distinguish it from AP. In some cases a drug-rash and/or eosinophilia may occur. Diagnosis requires careful exclusion of other aetiologies. However, the presence of other causes of AP does not entirely exclude DIP3.

The prognosis is generally excellent upon withdrawal of the medicine, and the DIP mortality rate is low1.

DIP can occur through multiple mechanisms, including direct toxicity, immunologic reactions, accumulation of toxic metabolites, ischaemia, intravascular thrombosis, and increased viscosity of pancreatic secretions. The time to onset varies depending on the mechanism, ranging from weeks to months after initiation of the medicine4.

New Zealand reports

Since 2009, the Centre for Adverse Reactions (CARM) has received 49 reports concerning 66 medicines suspected of causing pancreatitis. Table 1 shows some of the medicines reported to CARM and the number of positive dechallenges (withdrawal of medicine and cessation of symptoms) and rechallenges (restarting the medicine and reccurrence of symptoms).

Table 1: Selected medicines with reports received by CARM for pancreatitis reactions, 1 January 2009 to 31 December 2018

Medicine Reports Positive dechallengea Positive rechallengeb
Azathioprine 7 7  
Simvastatin 5 5  
Codeine 3 3 1
Ibuprofen 3 3  
Mesalazine 3 3  
Leflunomide 2 1 1
Olanzapine 2 2 1
Cannabis 1 1 1

Notes:

  1. Positive dechallenge: withdrawal of the medicine and cessation of symptoms.
  2. Positive rechallenge: restart the medicine and recurrence of symptoms.

Advice for healthcare professionals

Healthcare professionals should consider medicines as a potential cause of pancreatitis, particularly when there is a temporal relationship with starting a medicine. If you suspect a medicine has caused pancreatitis, withdraw the medicine. Report any suspected cases of DIP to CARM.

References
  1. Balani AR, Grendell JH. 2008. Drug-induced pancreatitis: incidence, management and prevention. Drug Safety 31(10): 823–37. DOI: 10.2165/00002018-200831100-00002 (accessed 3 April 2019).
  2. Pendharkar SA, Mathew J, Zhao J, et al. 2017. Ethnic and geographic variations in the incidence of pancreatitis and post-pancreatitis diabetes mellitus in New Zealand: a nationwide population-based study. New Zealand Medical Journal 130(1450): 55–68. URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1450-17-february-2017/7159 (accessed 7 May 2019).
  3. Spanier BW, Tuynman HA, van der Hulst RW, et al. 2011. Acute pancreatitis and concomitant use of pancreatitis-associated drugs. The American Journal of Gastroentergology 106(12): 2183–8. DOI: 10.1038/ajg.2011.303 (accessed 5 April 2019).
  4. Vege SS. 2019. Etiology of acute pancreatitis. In: UpToDate 9 January 2019. URL: www.uptodate.com/contents/etiology-of-acute-pancreatitis/ (accessed 3 April 2019).
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