S1533 A Unique Case of Mirtazapine Induced Hypertriglyceridemia Causing Acute Pancreatitis
Mohammad Asim AmjadZamara HamidKhalid AhmedAbdul Ahad Ehsan SheikhMahesh CheryalaMladen JecmenicaBeshir Saeed
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Introduction: Drug-induced pancreatitis is generally mild to moderate in intensity, but severe and even fatal cases have been observed and have now been linked with increased morbidity. This case outlines an interesting incidence of mirtazapine-associated hypertriglyceridemia that contributed to the development of acute pancreatitis. Case Description/Methods: We describe a 33-year-old female who presented to us with intractable nausea and acute abdominal pain. Physical examination was unremarkable except for severe epigastric pain on palpation. Laboratory workup was significant for elevated lipase levels (700U/L) and severe hypertriglyceridemia (>1000 mg/dL). CT scan of the abdomen revealed edema around the pancreas, suggesting inflammation, and ruled out any other pathology. Her history was uneventful except for depression and anorexia, for which she was recently started on Mirtazapine. She denied any recent history of alcohol or any other illicit drug use. Mirtazapine was then suspected as the cause of severe hypertriglyceridemia that led to acute pancreatitis. After discontinuing the offending agent, she was started on an insulin infusion and underwent multiple plasmaphereses. Subsequently, her triglyceride levels normalized with the resolution of her acute symptoms. Discussion: Pancreatitis can have multiple etiologies, of which drug-induced pancreatitis accounts for less than 5%, but cases may be higher owing to inconspicuousness. The pathophysiology varies depending on the medication and includes an accumulation of toxic metabolites, direct cytotoxic effects, or hypersensitivity reactions. Mirtazapine is an antidepressant drug usually prescribed for the treatment of major depressive disorder and anorexia. Although it does cause high serum triglyceride levels, the development of acute pancreatitis is a rare entity. As recommended by Mallory and Kern to prove a definitive diagnosis, a medication re-exposure test was not performed due to ethical reasons (1). Physicians must be aware of this association so that patients being given Mirtazapine should be monitored closely. Also, a quick diagnosis based on the association can help prompt cessation of the drug, which paves the way for a favorable outcome that can help avoid morbidity, reduce hospitalization stay and decrease medical expenditures.Figure 1.: Figures (a & b) show diffuse pancreatic parenchymal enlargement, indistinct pancreatic margins, and surrounding retroperitoneal fat stranding owing to inflammation suggestive of acute pancreatitis.Keywords:
Mirtazapine
Epigastric pain
Anorexia
Dyslipidemia
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Objective:To study the relationship between acute pancreatitis and serum triglyceride contents.Methods:The levels of serum triglyceride and clinical data in 447 patients with acute pancreatitis admitted in our hospital from 2002～2007 were retrospectively analyzed.Results:Hypertriglyceridemia was observed in 24.2% patients.The incidence of hypertriglyceride-mia in severe acute pancreatitis was higher than that of mild acute pancreatitis.However,no significantly difference of the levels of triglyceride was found in that's two groups.The APACHE-II scores,computer tomography severity index(CTSI) and length of hospitalization in groups with higher triglyceride(TG≥11.3 mmol/L)were higher than that of groups with lower triglyceride(TG11.3 mmol/L)and normal groups.Conclusion:Patients with acute pancreatitis often have hypertriglyceridemia.Hyperlipidemia may aggravate the diseases and antilipemic procedures should be given as earlier as possible.
Hyperlipidemia
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Hypertriglyceridemia is a rare cause of pancreatits. However the relationship between acute pancreatits and severe hypertrigyceridemia is well recognized. It can be a life- threatening complication if the degree of hypertrigyceridemia is severe enough. A serum triglyceride level of more than 1,000 to 2,000 mg/dL is the identifiable risk factor. The clinical course and management of hypertriglyceridemia induced acute pancreatitis is not different from other causes. The clinical course and management of hypertriglyceridemia induced acute pancreatitis during pregnancy are similar to the one during nonpregnant state. The prevalence of acute pancreatitis in pregnancy ranges between 1 in 1,000 to 1 in 3,000. Gestational hypertrigyceridemic pancreatits can be fatal, and maternal morbidity rate has an upward trend of 20%. We report a 31-year-old woman with coexistence of hypertrigyceridemia and acute pancreatits at 32 weeks gestation with a brief review of the literatures.
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Hypertriglyceridemia induced acute pancreatitis has become the third major cause of acute pancreatitis resulting in high morbidity and mortality. Currently, specific mechanism behind association between hypertriglyceridemia in diabetic population and the correlation of causing acute pancreatitis are still not well identified. This literature review summarizes recent understanding of the pathogenesis of hypertriglyceridemia in diabetic populations and its correlation with acute pancreatitis along with clinical management of this disease. Keywords: Hypertriglyceridemia, Pancreatitis, Diabetic Population
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A 39-year-old woman with a history of gestational diabetes was admitted with epigastric pain from acute pancreatitis. She had no history of hyperlipidemia, but multiple blood samples were grossly lipemic, and serum triglyceride levels were markedly increased.
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A 33-year-old male with acute pancreatitis induced by hypertriglyceridemia had problems during treatment with plasma exchange. The hypercoagulable state was prevented by introducing innovative methods for cleaning and warming of the circuit and dialyzer. This enabled successful therapy, and the patient fully recovered from life-threatening acute pancreatitis.
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Hypertriglyceridemia is an uncommon but a well-established etiology of acute pancreatitis leading to significant morbidity and mortality. The risk and severity of acute pancreatitis increase with increasing levels of serum triglycerides. It is crucial to identify hypertriglyceridemia as the cause of pancreatitis and initiate appropriate treatment plan. Initial supportive treatment is similar to management of other causes of acute pancreatitis with additional specific therapies tailored to lower serum triglycerides levels. This includes plasmapheresis, insulin, heparin infusion, and hemofiltration. After the acute episode, diet and lifestyle modifications along with hypolipidemic drugs should be initiated to prevent further episodes. Currently, there is paucity of studies directly comparing different modalities. This article provides a comprehensive review of management of hypertriglyceridemia induced acute pancreatitis. We conclude by summarizing our treatment approach to manage hypertriglyceridemia induced acute pancreatitis.
Plasmapheresis
Etiology
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