What medications should be avoided in a patient with Acute Pancreatitis (AP)?

Medications to Avoid in Acute Pancreatitis

No specific medications are absolutely contraindicated in acute pancreatitis except for lipid-containing parenteral nutrition during the acute phase and drugs known to have caused the pancreatitis in that individual patient. 1, 2

Medications That Should Be Avoided or Used With Extreme Caution

Lipid-Containing Parenteral Nutrition

• Lipid-containing parenteral nutrition must be avoided during acute management of pancreatitis, as it can worsen hypertriglyceridemia and exacerbate pancreatic inflammation. 2
• If parenteral nutrition is required, use lipid-free formulations initially and only introduce lipids once the acute phase has resolved and triglyceride levels are controlled. 1, 2

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

• NSAIDs should be avoided in patients with acute pancreatitis who have acute kidney injury (AKI), which is common in this population due to hypovolemia and systemic inflammation. 1
• This restriction is based on the nephrotoxic effects of NSAIDs in the setting of compromised renal perfusion, not a direct pancreatic effect. 1

Drugs That Caused the Pancreatitis

• If drug-induced pancreatitis is suspected or confirmed, immediately discontinue the offending agent. 3
• Class I medications (strongest evidence for causing pancreatitis) include: didanosine, asparaginase, azathioprine, valproic acid, pentamidine, mercaptopurine, mesalamine, estrogen preparations, opiates, tetracycline, steroids, trimethoprim/sulfamethoxazole, sulfasalazine, furosemide, and sulindac. 3
• Estrogen-containing oral contraceptives should be permanently discontinued if they caused hypertriglyceridemia-induced pancreatitis, as resumption carries high risk of recurrence. 4, 5

GLP-1 Receptor Agonists and DPP-4 Inhibitors

• Do not initiate GLP-1 receptor agonists in patients at high risk for pancreatitis, and discontinue immediately if pancreatitis is suspected. 1
• Discontinue DPP-4 inhibitors if pancreatitis is suspected, though causality has not been definitively established. 1
• These medications should not be restarted after an episode of acute pancreatitis without careful risk-benefit assessment. 1

SGLT2 Inhibitors

• Discontinue SGLT2 inhibitors during acute pancreatitis, particularly if the patient is critically ill, fasting, or undergoing surgery. 1
• The risk of euglycemic diabetic ketoacidosis (DKA) is elevated in patients with insulin deficiency and acute illness. 1

Important Clarifications About Pain Management

Opioids Are NOT Contraindicated

• Despite historical concerns, opioids are safe and appropriate for pain control in acute pancreatitis. 1, 6
• Dilaudid (hydromorphone) is preferred over morphine or fentanyl in non-intubated patients. 1
• Patient-controlled analgesia (PCA) should be integrated into a multimodal pain management approach. 1
• Epidural analgesia is an excellent alternative for patients requiring high-dose opioids for extended periods. 1

Common Pitfalls to Avoid

• Do not withhold appropriate pain medication based on outdated concerns about sphincter of Oddi spasm—there is no evidence supporting restriction of any specific analgesic. 1
• Do not overfeed with parenteral nutrition, as this worsens hyperglycemia, hepatic dysfunction, and overall outcomes; limit to 25-30 kcal/kg/day maximum. 1, 2
• Do not abruptly discontinue insulin therapy in diabetic patients with pancreatitis, as this can lead to rebound hyperglycemia and ketoacidosis. 2, 7
• Monitor for refeeding syndrome in malnourished patients or those with chronic alcoholism when initiating nutrition support; supplement potassium, magnesium, phosphate, and thiamine appropriately. 1