There has been great progress in the treatment of acute pancreatitis, but it remains the third most common reason for hospitalization and the fifth most expensive gastrointestinal disease to treat in the United States as of 2018, Timothy B. Gardner, MD, MS, FACG, told the attendees at the American College of Gastroenterology 2020 Postgraduate Course.

Dr Gardner is an associate professor at the Geisel School of Medicine at Dartmouth and director of the Gastroenterology and Hepatology Fellowship Program at Dartmouth-Hitchcock Medical Center in Dartmouth, New Hampshire.

Despite the progress in areas such as nutritional support and fluid collection, and the fact that the mortality rate is dropping, acute pancreatitis remains “one of the most common and deadly gastrointestinal diseases” in the United States, Dr Gardner stated, subsequently asking, “Why are patients still dying?”

One problem lies in the fact that major society guidelines for diagnosing and managing this disease “address classification, severity, risk stratifying, and managing complications, but do not evaluate treatment,” he said. “There just wasn’t the evidence available to evaluate treatment.”

But by far “the most abject failure” is the lack of any approved therapy for acute pancreatitis. “That is a real problem. It’s all supportive care. There is nothing that will alter the natural history of this disease,” Dr Gardner stressed. “Until a targeted pharmacological therapy can be developed, patients will still die from acute pancreatitis.”

He observed that the reasons for the lack of a therapy “are not from lack of trying.” There have been efforts to develop drugs that initially created great excitement and interest but in multicenter randomized trials did not demonstrate significant benefits. Part of the problem, Dr Gardner said, is that “we do not have a concrete understanding, like we do in IBD, of the underlying mechanisms that cause acute pancreatitis.”

He also said that there is a lack of industry investment and interest among the large pharmacy firms. “There is also a lack of overlap diseases with acute pancreatitis.”  But most of all, “these are extraordinarily difficult studies to enroll. When does the time clock start for treatment? At symptom onset? When patients come for admission? When they are hospitalized? Most patients have symptoms for hours or even days before they present for treatment. Because this is an acute problem, it can be very hard to establish that time clock,” Dr Gardner explained.

Patients are in severe pain when they present to the emergency department or for admission to the hospital, but they do generally have decision-making capacity, Dr Gardner continued. “So when you approach a patient for a study when they’re suffering, it’s very hard to enroll them in trials. And most patients with acute pancreatitis do not present to research institutions.”

However, he emphasized, “I do have a lot of hope for the future.” He praised the Rand Process from the ACG task force on quality that developed quality metrics for the management of patients with acute pancreatitis. “Management metrics are really important. You wouldn’t think diagnosis would be difficult with acute pancreatitis, but sometimes it can.” These indicators also address initial assessment and risk stratification, and an initial management domain. Nutrition is extremely important, as well, he said.

Dr Gardner also discussed the many different studies now enrolling for treatment of acute pancreatitis, on subjects ranging from saline to experimental drugs to using infliximab. “We have pharmacological treatments in the pipeline. We have quality metrics. This is all very, very encouraging,” he said.

—Rebecca Mashaw

Reference:

Gardner, TB. Acute pancreatitis: why are patients still dying? Talk presented at: American College of Gastroenterology postgraduate course. October 24, 2020. Virtual