A case of salicylazosulfapyridine (salazopyrin)-induced acute pancreatitis with positive Lymphocyte stimulation test (LST)

Abstract

A case of acute pancreatitis induced by salicylazosulfapyridine (Salazopyrin, SASP) was reported. A 33-year-old man with ulcerative colitis was given SASP. Five weeks later, P-type serum amylase was found to be elevated. The amylase/creatinine clearance ratio (ACCR) and serum lipase were also elevated. There were neither subjective symptoms nor abnormal ultrasound findings in the pancrease. Lymphocyte stimulation test (LST) to SASP was positive. Asymptomatic pancreatitis by SASP was suspected and SASP administration was halted. Afterwards the abnormal data became normal. Readministration of SASP because of relapse caused an episode of pancreatitis similar to the first occasion. LST was negative before SASP intake and became positive after intake. Desensitization to SASP was unsuccessful. LST was negative before attempting desensitization and became positive when the dosage of SASP increased to 100 mg daily. This is the second case of acute pancreatitis reported to be induced by SASP and this is the first case in which LST to SASP was described. To our knowledge, this is also the first case in which a positive LST was described in drug-induced pancreatitis. This case provides evidence for the role of delayed type hypersensitivity in the etiopathogenesis of SASP allergy and of dose-independent drug-induced pancreatitis.

5-ASA Induces Mild Acute Pancreatitis. Case Report and Review of the Literature

“…In the cases which reported severity, AP was usually mild (73.7%) [2,5,11,19,22,25,28,38], one moderately severe episode was found [31], and of the four severe cases reported [4,20,32], two were lethal; 60.5% of the identified patients (n=26) were rechallenged positively with one of the formulations of the 5-ASA. After discontinuation of the offending drug, symptoms usually disappeared quickly [3,12,14,15,18], as observed in our case as well.…”

“…We analyzed the clinical course of 5-ASA-induced AP cases found on the systematic literature search. Hypersensitivity [1,2,11,15,37] and idiosyncrasy [1,29] are usually thought to be involved in the pathogenic mechanism of 5-ASA-induced AP (according to 38.9% of the authors). In most of the identified cases, the reaction seemed not to be dose-dependent, however, the specific underlying mechanism remained a matter for speculation.…”

“…The latency between intake of 5-ASA and onset of pancreatitis usually varied between a few days and a few months, however, DIAP can occur after long term treatment as well [4,12,21,28,35,39]. The route of administration [4,25,29,31,39] (either oral or rectal) and use of coated formulations [1][2][3]17] (time-or pH-dependent) did not appear to affect the risk of AP, and in most of the cases, there was a rapid recurrence if rechallenged [3,12,14,15,18]. 5-ASA induced AP was usually self-limited.…”

Retrospective Matched-Cohort Analysis of Acute Pancreatitis Induced by 5-Aminosalicylic Acid–Derived Drugs

“…Pancreatitis as an adverse reaction to 5-ASA–derived drugs was first reported in 1970 by Block et al 8 and was followed by several others. 9–11 According to the literature, DIAP is usually considered self-limited and mild in clinical course, with easy management, an excellent prognosis, and low mortality. 6 Rapid symptomatic improvement usually occurs after discontinuation of the offending medication.…”

Drug-Induced Acute Pancreatitis: Further Criticism

“…Two patients with inflammatory bowel disease had anecdotal evidence for salicylazosulfapyridine-induced pancreatitis [211], In 2 patients with Crohn's disease recurrent pan creatitis after controlled rcchallengc with salicylazosulfapyridine was demonstrated [212,213], A 5th patient with salicylazosulfapyridine treatment of ulcerative colitis had recur rent hyperamylasemia and a positive lym phocyte stimulation test for salicylazosulfapyridine [214], A 6th patient developed ab dominal pain under salicylazosulfapyridine for ulcerative colitis, and 2 years later experi enced clinical pancreatitis under sulfame thoxazole and a positive lymphocyte stimula tion test with sulfonamides, but not with 5-aminosalicylic acid [36]. Another patient de veloped pancreatitis while under treatment with salicylazosulfapyridine.…”