Simvastatin-Induced Acute Pancreatitis: A rare side effect of a statin

Abstract

A cute Pancreatitis is defined as the abrupt nonbacterial inflammation of the pancreas. Typical symptoms comprise abdominal pain located in the epigastrium and radiating to the back. In the majority of cases, the progression of acute pancreatitis is mild and self-limited. Albeit, one fifth of patients may deteriorate and develop multiple organ dysfunction syndrome (MODS) which eventually enhances mortality rate. 1,2 The first and second most common etiologies, accounting for approximately 75% of cases in most developed countries, are gallstones and alcohol respectively. 3 Less common causes include pancreatitis occurring after endoscopic retrograde cholangiopancreatography (ERCP), abdominal trauma, familial hypertriglyceridemia, hypercalcemia, autoimmune disease, toxins, etc. 4,5 Drug-induced pancreatitis is a relatively rare occurrence, accounting for approximately 1.2-2% of cases. 6-8 Of those, acute pancreatitis caused by the 3-hydroxy-3methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, often referred to as statins, has been reported rarely. 9 We reported a case experiencing the very rare side effect of simvastatin-associated acute pancreatitis. This information should increase awareness of physicians and pharmacists not to overlook the etiology particularly in any patients diagnosed with idiopathic pancreatitis. Case ReportAn 84-year-old Thai man was admitted to hospital outside Bangkok on April 15, 2013 (Day 1) due to acute epigastric pain radiating to the middle of the back, without nausea or vomiting. The attack occurred after dinner and lasted for 10 hours prior to admission. He had underlying diseases of hypertension (HT), coronary artery disease (CAD), and hypertrophy of the prostate gland and these conditions were well-controlled by oral medications including simvastatin (40 mg once daily), aspirin (81 mg once daily), amlodipine (5 mg once daily), trimetazidine hydrochloride (35 mg twice a day), and alfuzosin (10 mg once daily). He had been taking these medications since diagnoses were made in 2007. Alcohol consumption was stopped more than 10 years previously.On physical examination, the patient was alert. Vital signs: BP 120/70 mmHg, HR 80/min, T 37.8 o C, RR 22/min. Body mass index was 26.1 kg/m 2 . The cardiopulmonary system was unremarkable. Abdominal examination revealed no guarding but with generalized rebound tenderness; hepatosplenomegaly could not be detected. There was no cutaneous sign of chronic liver disease.Hematologic studies revealed the following findings: pancreatic amylase (P-amylase) 2,598 U/L (normal: 8-53 U/L), no lipase level performed before transfer, total bilirubin 2.8 mg/dL (normal: 0-1.5 mg/dL), direct bilirubin 2.1 mg/dL (normal: 0-0.5 mg/dL), aspartate aminotransferase (AST) 136 U/L (normal: 0-40 U/L), alanine