What is the management plan for a patient with suspected Jardiance (Empagliflozin)-induced pancreatitis?

Management of Suspected Jardiance (Empagliflozin)-Induced Pancreatitis

Immediately discontinue empagliflozin and do not rechallenge, as drug-induced pancreatitis requires permanent withdrawal of the offending agent to prevent recurrence and potential fatal outcomes. 1, 2

Immediate Actions

Discontinue the Offending Agent

• Stop empagliflozin immediately upon suspicion of drug-induced pancreatitis. 1, 2
• Do not rechallenge with empagliflozin or other SGLT2 inhibitors, as recurrent pancreatitis upon rechallenge provides the strongest evidence for drug causation. 2
• Transition diabetes management to alternative agents such as metformin or sulfonylureas (as demonstrated in the empagliflozin case report where the patient was successfully discharged on metformin and glipizide). 1

Confirm Diagnosis and Exclude Other Etiologies

• Measure serum lipase and amylase levels (lipase is preferred as it is more specific). 3
• Obtain abdominal ultrasound immediately to evaluate for gallstones or choledocholithiasis. 3
• Check serum triglycerides, calcium, and liver function tests to exclude metabolic causes. 3, 4
• Assess for alcohol use, as this is a common etiology that must be excluded. 1
• Obtain CT with IV contrast if diagnosis is unclear or patient fails to improve clinically within 48-72 hours. 3, 4

Initial Resuscitation and Supportive Care

Fluid Resuscitation

• Initiate aggressive goal-directed intravenous fluid resuscitation immediately, as this is most beneficial within the first 12-24 hours. 5, 4
• Avoid hydroxyethyl starch (HES) fluids due to increased risk of multiple organ failure. 3
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate as indicators of adequate volume status and tissue perfusion. 3, 5

Pain Management

• Provide multimodal analgesia with hydromorphone preferred over morphine or fentanyl in non-intubated patients. 5, 6
• Use IV pain medications for moderate to severe cases. 3
• Avoid NSAIDs if acute kidney injury is present. 5, 6
• Consider epidural analgesia for severe pancreatitis requiring high-dose opioids for extended periods. 5

Nutritional Management

Early Feeding Strategy

• Initiate early oral feeding within 24 hours if the patient has no nausea or vomiting, rather than keeping nil per os. 3, 5
• Advance diet as tolerated with a regular diet in mild cases. 3

Enteral vs Parenteral Nutrition

• For patients unable to tolerate oral intake, use enteral nutrition (oral, nasogastric, or nasojejunal) rather than parenteral nutrition to prevent infectious complications. 3, 5
• Either nasogastric or nasojejunal routes are acceptable for enteral tube feeding. 3
• Reserve total parenteral nutrition only for patients who cannot tolerate enteral nutrition. 3

Antibiotic Management

• Do not use prophylactic antibiotics routinely, even in predicted severe or necrotizing pancreatitis. 3, 5
• Administer antibiotics only when specific infections occur (respiratory, urinary, biliary, or catheter-related). 5, 6
• If infected necrosis develops (suspected with persistent fever, leukocytosis, or clinical deterioration after 7-10 days), obtain CT-guided fine needle aspiration for culture and initiate appropriate antibiotic therapy. 3

Severity-Based Management

Mild Pancreatitis

• Regular diet and advance as tolerated. 3
• Oral pain medications. 3
• Routine vital signs monitoring. 3

Moderately Severe Pancreatitis

• Enteral nutrition (oral, NG, or NJ) if oral intake not tolerated. 3
• IV pain medications and fluids. 3
• Monitor hematocrit, blood urea nitrogen, and creatinine. 3
• Continuous vital signs monitoring. 3

Severe Pancreatitis

• Manage in intensive care unit or high dependency unit with full monitoring and systems support. 3, 6
• Enteral nutrition preferred; parenteral if not tolerated. 3
• Early aggressive fluid resuscitation. 3
• Mechanical ventilation if needed. 3

Monitoring and Follow-Up

• Monitor C-reactive protein and procalcitonin (PCT is the most sensitive test for detecting pancreatic infection). 3
• Perform CT with IV contrast at 3-10 days in severe cases or if patient fails to improve to assess for necrosis and complications. 3, 6
• Document the temporal relationship between empagliflozin initiation and pancreatitis onset (typically occurs within 2-4 weeks of starting the medication). 1, 7

Key Clinical Pitfalls

• Do not rechallenge with empagliflozin or switch to another SGLT2 inhibitor, as class effect cannot be excluded and recurrence may be more severe or fatal. 2
• Drug-induced pancreatitis is commonly overlooked in patients with multiple comorbidities taking numerous medications—maintain high index of suspicion with new medication starts. 8, 2
• The majority of drug-induced pancreatitis cases are mild, but severe and fatal cases can occur, making identification critical. 2
• SGLT2 inhibitor-associated pancreatitis is increasingly recognized but remains underreported; physicians must consider this diagnosis after excluding common etiologies. 1