Advocate Lutheran General Hospital Park Ridge, IL, United States
Ryan T. Hoff, DO1, Mary DeMent, DO1, Hina Omar, MD1, Branden C. Chi, 2 1Advocate Lutheran General Hospital, Park Ridge, IL; 2Glenbrook North High School, Chicago, IL
Introduction: Acute pancreatitis (AP) occurs at 4.9-35 persons per 100,000 population in the US. Drug-induced pancreatitis (DIP) occurs in < 5% of cases. Dupilumab is a monoclonal IgG4 antibody approved for atopic dermatitis. We describe a patient with AP recently started on dupilumab for severe atopic dermatitis. This would represent the first case of dupilumab-associated DIP in an adult.
Case Description/Methods: A 40-year-old Hispanic male, with obesity and severe atopic dermatitis, presented for one day of severe, worsening, epigastric abdominal pain. He had no history of similar presentation, other symptoms, or recent illness. There was no history of daily or binge alcohol drinking or tobacco or drug use. He denied a family history of pancreatitis or pancreatic malignancy. He recently started dupilumab for atopic dermatitis, the first dose given 3 months prior. Due to insurance delays, the second dose was delivered 1-2 days prior to presentation. On arrival, exam was notable for epigastric tenderness to palpation. Lipase was 1684 units/L and ALT 70 units/L with otherwise unremarkable labs. Four years ago, his ALT was 42 units/L and AST was 39 units/L. A gallbladder ultrasound found tumefactive sludge or small non-shadowing gallstones, normal biliary ducts, a 5-millimeter in diameter common bile duct, and no evidence of inflammation. A CT of the abdomen with IV contrast demonstrated subtle peripancreatic inflammatory fat stranding, hypodense hepatic parenchyma compatible with hepatic steatosis, and no evidence of biliary or gallbladder abnormalities. Triglycerides were 66 mg/dL. His calcium was normal. He received aggressive intravenous fluids and initially nothing by mouth (NPO). Over a 6-day hospitalization, his pain resolved. His diet slowly advanced. On discharge, he was advised regarding reevaluation of liver enzymes and gallbladder ultrasound, avoiding dupilumab, and considering cholecystectomy if pancreatitis recurred off dupilumab. At 2 months post discharge, there was no recurrence of pancreatitis.
Discussion: Using Badalov classification to elucidate DIP is difficult due to medication rechallenge side effects. This case’s Naranjo score of two reflects a possible correlation between dupilumab and DIP. The gallbladder sludge may be due to NPO status. The elevated liver enzymes could be due to non-alcoholic fatty liver disease, previously evident. In this case of AP, with no evidence of biliary obstruction or sequelae, the only correlation is recent initiation of dupilumab for atopic dermatitis.
Figure: Figure 1. Computed tomography with intravenous contrast demonstrating subtle peripancreatic inflammatory fat straining of the pancreatic head and uncinate process and hypodense hepatic parenchyma consistent with hepatic steatosis.
Disclosures: Ryan Hoff indicated no relevant financial relationships. Mary DeMent indicated no relevant financial relationships. Hina Omar indicated no relevant financial relationships. Branden Chi indicated no relevant financial relationships.
Ryan T. Hoff, DO1, Mary DeMent, DO1, Hina Omar, MD1, Branden C. Chi, 2. P0086 - Dupilumab Associated Drug Induced Pancreatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.