Acute Pancreatitis Induced by Telmisartan Overdose

Abstract

Acute pancreatitis induced by telmisartan overdoseTO THE EDITOR: Angiotensin II receptor antagonists (ARBs) are widely used for the management of hypertension and heart failure because of their proven efficacy and high tolerability. In most randomized clinical trials, the proportion of patients reporting adverse effects or being withdrawn because of them was similar to that with placebo. 1 However, postmarketing surveillance has revealed the occurrence of some adverse events with ARBs. Mild acute pancreatitis has been reported with both irbesartan and losartan in 1 and 3 cases, respectively. 2 As far as we are aware, as of April 15, 2004, pancreatitis has previously never been reported with telmisartan. We describe a patient who developed biochemical alterations, suggesting acute pancreatitis, after a suicidal attempt with high doses of telmisartan and oxazepam.Case Report. A 77-year-old white man diagnosed with mild hepatitis C virusrelated chronic liver disease, hypertension, and depression was admitted to the emergency department because he had taken 28 tablets of telmisartan 80 mg and 20 tablets of oxazepam 30 mg 8 hours earlier. On admission, he reported only mild and transient abdominal pain, and his wife observed that he had slept all afternoon. The patient exhibited a depressed mood without impairment of cognitive function or signs of neurologic deficits.Physical examination was unremarkable, and vital signs were stable except for blood pressure 90/65 mm Hg; electrocardiogram and chest X-ray were normal. Baseline laboratory investigations showed normal levels of leukocytes, aspartate aminotransferase, alanine aminotransferase, γ-glutamyltransferase, triglycerides, creatinine, and electrolytes, but a marked increase of amylase blood levels ( Table 1). The patient denied past or recent alcohol abuse or abdominal trauma, and an ultrasound ruled out gallstones and biliary tract or pancreatic abnormalities. Normal results from a routine biochemistry evaluation, performed 10 days before, excluded other diseases.The patient was admitted, and activated charcoal 30 g and magnesium sulfate 30 g were immediately administered, but a gastric lavage was not performed because of the time that had passed since drug ingestion. Hypotension was treated with intravenous fluids. An infusion of gabexate mesilate 900 mg/day was started and continued for 3 days. Subsequent laboratory investigations were negative for autoantibodies or signs of hyperparathyroidism. The patient remained asymptomatic, and the biochemical alterations were normal at discharge (3 days later).

Fatal Acute Pancreatitis in a Patient Chronically Treated with Candesartan

“…One patient reportedly developed a case of mild pancreatitis after taking an overdose of the ARB telmisartan, thus hinting at a possible dose-response relationship. 23 An argument against candesartan being causal in our patient was the fact that he had been using this drug for over a year, with no proven evidence of prior attacks of pancreatitis. However, this does not exclude the possibility that drug-induced pancreatitis might occur after considerable delay or that candesartan may have acted in concert with some other unrecognized cofactor in the genesis of pancreatitis in this patient.…”

Postmortem blood concentrations of sartans measured by liquid chromatography-tandem mass spectrometry

“…The refractory hypotension was successfully treated with naloxone and vasopressin. The second overdose case was a 77-year-old man who ingested a 2240 mg overdose of candesartan exhibited abdominal pain and a marked increase in serum amylase levels, consistent with acute pancreatitis but the symptoms were resolved within 2 days [8]. However, fatal sartan overdoses have not yet been reported.…”