Click here to get ACPE CE credit for listening to this episode.
In this episode, I’ll discuss drug-induced pancreatitis.
The Critical Care Pharmacy Academy is a place for pharmacists and pharmacy residents to gain practical critical care knowledge and skills. Inside the Academy you will find monthly Masterclasses, weekly critical care literature digests, and members-only forums to connect with other pharmacists and get answers to your critical care pharmacy questions.
You can learn more by going to pharmacyjoe.com/academy.
The incidence of drug-induced pancreatitis is less than 2% of all pancreatitis cases. There are no clinical features that differentiate drug-induced pancreatitis from other types. Typically, drug-induced pancreatitis is considered if a patient has pancreatitis without an obvious cause.
When evaluating potential drug-induced pancreatitis, first check to make sure a more common cause such as alcohol use/abuse, gallstones, hypertriglyceridemia, or a history of recent ERCP is not present. Next, consider whether the patient has been taking any medications thought to cause pancreatitis.
Medications
The majority of data for medications reported to cause pancreatitis are case reports. The World Health Organization maintains a database of over 500 drugs thought to cause pancreatitis, but only 30 of those drugs are thought to have “definitely” caused pancreatitis according to the Naranjo adverse drug reaction algorithm. Those medications are:
Acetaminophen
Asparaginase
Azathioprine
Bortezomib
Capecitabine
Carbamazepine
Cisplatin
Cytarabine
Didanosine
Enalapril
Erythromycin
Estrogen
Furosemide
Hydrochlorothiazide
Ifosfamide
Interferon α2b
Isoniazid
Itraconazole
Lamivudine
Mercaptopurine
Mesalamine/Olsalazine
Metronidazole
Octreotide
Olanzapine
Opioids
Pentamidine
Pentavalent anti-monials
Phenformin
Steroids
Sulfasalazine
Sulfamethoxazole/Trimethoprim
Sulindac
Tamoxifen
Tetracycline
Valproic acid
Vemurafenib
Of particular note on this list is the absence of any GLP-1 inhibitors. Many cases of acute pancreatitis have been reported in patients taking GLP-1 inhibitors such as exenatide, liraglutide, albiglutide, taspoglutide, and lixisenatide. To examine this potential link, multiple cohort studies have been performed. These studies have not shown an association between GLP-1 inhibitors and acute pancreatitis. Nevertheless, if I was evaluating a patient for drug-induced pancreatitis and they were taking a GLP-1 inhibitor, I would discontinue it and search for an alternative treatment.
Mechanisms of drug-induced pancreatitis
There are at least six different mechanisms by which medications are thought to cause pancreatitis. Because of these mechanisms, the onset of pancreatitis may be delayed compared to when a suspected medication is begun. The six mechanisms are:
1. Immunologic reaction
2. Direct effect
3. Accumulation of toxic metabolites
4. Ischemia
5. Thrombosis
6. Thickening of pancreatic secretions
The strongest case for drug-induced pancreatitis in a particular patient comes after a positive rechallenge, but this is usually not clinically done. It would be rare not to be able to find a suitable alternative to a medication suspected of causing pancreatitis.
Summary
To summarize, my approach to evaluating a patient with suspected drug-induced pancreatitis is to:
1. Check for common causes of pancreatitis
2. Check for medications known to cause pancreatitis
3. Apply the Naranjo algorithm
4. Discontinue and propose alternative treatments
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Leave a Reply