Recurrent Acute Pancreatitis Probably Secondary to Lisinopril

Objectives: Few data exist about the incidence of drug-induced acute pancreatitis in the general population. Although angiotensin-converting enzymes are generally well tolerated, acute pancreatitis has been reported in a few subjects treated with captopril, enalapril, and lisinopril. However, to our knowledge, there is no published data regarding recurrent pancreatitis secondary to lisinopril. Herein, we report the case of a 54-year-old man who developed recurrent acute pancreatitis after starting lisinopril.

Clinical Presentation: A 54-year-old man with a longstanding history of hypertension, treated with lisinopril 10 mg once daily, presented with acute pancreatitis. Other causes of the disease were ruled out. After cessation of lisinopril, his condition improved and his amylase level decreased. This was his third episode of acute pancreatitis since lisinopril had been started in 2002. After discontinuing lisinopril and beginning treatment with amlodipine 10 mg/d, the patient was well at follow-up examination and has not had another episode of pancreatitis during the subsequent 7 months.

Conclusion: This case report demonstrates additional evidence of acute pancreatitis associated with an ACE inhibitor.

Key Points

* Lisinopril might be a cause of recurrent acute pancreatitis.

* Physicians should keep ACE inhibitors in mind when considering the differential diagnosis of recurrent pancreatitis.

* Physicians should be vigilant in monitoring for signs and symptoms of pancreatitis when their patients are on ACE inhibitors.

Medication-related pancreatitis occurs in approximately 1.4 to 2% of patients,¹ and the use of angiotensin-converting enzyme (ACE) inhibitors for the treatment of heart failure and hypertension is increasing. There have been several published reports^1,2 of ACE inhibitor-associated pancreatitis. The offending agents have included captopril, enalapril, quinapril, ramipril, perindopril and lisinopril.^1-7 This case report demonstrates additional evidence of acute pancreatitis associated with an ACE inhibitor. We describe the case of a 54-year-old man who developed recurrent acute pancreatitis after taking lisinopril.

Case Report

A 54-year-old man presented to the gastroenterology department with a 1-day history of sudden onset, severe abdominal pain radiating to the back, plus nausea. He had no previous medical or surgical history, no history of alcohol use, no history of trauma. Before admission, his medication regimen consisted only of lisinopril 10 mg b.i.d. for arterial hypertension for 25 months. He had two previous episodes of acute pancreatitis after starting the lisinopril. His first acute episode of pancreatitis was 4 months after beginning lisinopril, and the second occurred 10 months later. Previous investigations included abdominal ultrasonography and endoscopic retrograde cholangiopancreatography, which had ruled out common causes of pancreatitis.

On physical examination, the patient's abdomen was distended and diffusely tender. His bowel sounds were reduced. Blood tests revealed an amylase of 997 IU/mL (reference range: 0-180 IU/mL), lipase 1368 U/L (reference range: 40-110), a raised white cell count of 14,000 (reference range: 4,500-11,000) and a moderately elevated C-reactive protein level at 82 mg/L (reference range: 0-10 mg/L). The other laboratory tests, including serum calcium, lipids, thyroid, renal, and liver function tests, were normal. Abdominal ultrasonography showed pancreatic edema, whereas the rest of the pancreas was normal. The biliary tree was not dilated and no gallstones were seen. The patient was diagnosed with acute pancreatitis. Occult biliary disease (microlithiasis) or damage to the ampullary region and congenital variation of the pancreatic duct system was excluded by endoscopic retrograde cholangiopancreatography. The only significant factor in our patient's history was the three episodes of acute pancreatitis since beginning the lisinopril.

The patient's clinical status quickly and spontaneously improved within 3 days of lisinopril cessation. His serum amylase level returned to normal on day 3 after discontinuing lisinopril. The patient was discharged from the hospital 4 days after admission. After discontinuing lisinopril, he was well at his follow-up visit with amlodipine 10 mg/d. The patient has not had another episode of pancreatitis during the subsequent 7 months.

Discussion

Drug-induced pancreatitis has no distinguishing features. The occurrence of reported cases of pancreatitis secondary to ACE inhibitors is relatively rare and mostly associated with captopril, enalapril, quinapril, ramipril, perindopril and lisinopril.^1-9 ACE inhibitors are first line agents in cardiovascular disease. Time intervals between the start of ACE-inhibitor treatment and the onset of acute pancreatitis varies and ranges between 1 day to 2 years, but generally occurs early in the course of therapy.^1-3 The severity of acute pancreatitis is usually mild. The pathogenesis of drug-induced pancreatitis may be caused by an allergic response or by a direct toxic effect. Pancreatitis associated with ACE inhibitors is thought to reflect localized angioedema of the gland.^1-3 Angioedema due to ACE inhibitors appears to be linked to the decreased degradation of bradykinin because ACE, also known as kininase II, not only activates angiotensin I but also inactivates bradykinin. Angiotensin II receptors are thought to be important in the regulation of pancreatic secretion and microcirculation, and this may have an additive effect on pathogenesis.^1-3,8 Proving the association with a particular drug may not always be straightforward, even in suspected cases. Thus, patients restarted on their medications should be closely monitored and the drug promptly discontinued if symptoms recur, as in our patient.¹ Use of the Naranjo probability scale indicates a probable relationship between recurrent acute pancreatitis and lisinopril in this patient.⁴ The adverse reaction appeared after lisinopril was initiated, resolved promptly on withdrawal of the drug, and as the patient was on no other regular medications, lisinopril was the most likely etiologic agent. Reintroduction of lisinopril therapy resulted in the recurrence of pancreatitis, which strongly supports this association. Despite the low incidence of drug-induced pancreatitis, all patients with acute pancreatitis of unknown etiology should be carefully questioned regarding their medication history. In addition to monitoring for efficacy and commonly reported adverse effects, clinicians need to be aware that acute pancreatitis may occur in patients taking ACE inhibitors. If pancreatitis is suspected, the drug should be stopped and replaced to reduce the possibility of further episodes of pancreatitis.

This case suggests that when ACE-inhibitor treatment is started, clinicians should be vigilant in monitoring for signs and symptoms of pancreatitis.