Was it really pancreatitis from GLP-1 receptor agonist therapy?
1
W e read with interest the recent publications alluding to the link between GLP-1 receptor agonist therapy (GLP-1RA) and the risk of acute pancreatitis. 1–5 We write to highlight that this seems at odds with our own expe- rience in two nationwide audits of GLP-1RA use, with the reported cases of pancreatitis being very rare in both audits. The Association of British Clinical Diabetologists (ABCD) conducted audits on the use of exenatide twice daily (2007–2009) and liraglutide (2009 – ongoing) to evaluate the safety and efficacy of these agents in real-life clinical practice. The structure and major findings of the exenatide audit, including the reported cases of acute pancreatitis, were published previously in this journal. 6 We have also recently reported on the frequency of acute pancreatitis among patients in the liraglutide audit. 7 The pertinent feature of both audits was the specific enquiry into the occurrence of pancreatitis in the audit query. To our knowledge, both audits are as yet still the largest reported audits of GLP-1RA use in clinical practice (6717 and 6010 patients, respectively). ABCD received grants from Eli Lilly and Novo Nordisk for these audits, but the audits were conducted independently of the pharmaceuti- cal companies, as was the reporting of pancreatitis cases from the individual participating sites. As published previously, there were four cases of acute pancreatitis reported in the ABCD nationwide exenatide audit. After scrutiny of each reported case, three cases had alternative causes for the episode of pancreatitis – gall- stones, significant alcohol consumption and significant hypertriglyceridaemia. Only one case had no obvious alter- native cause. 6 The audit monitored 3336 years of exposure to exenatide. With one case which might be related to exenatide therapy, this represents an incidence of 0.030 per 100 patient years of exposure to exenatide. The equiv- alent finding in the ABCD nationwide liraglutide audit was one possible related case among 3720 monitored years of exposure, representing an incidence of 0.027 per 100 patient years of exposure to liraglutide. 7 Key factors A key lesson we learned from conducting the audits was that the correct adjudication of pancreatitis cases is extremely important, especially when the frequency of an adverse event is very low. There were three reported cases of abdom- inal pains in the exenatide audit with concerns for pancre- atitis but with subsequent normal amylase levels. These were deemed not to be cases of pancreatitis. A particular strength of the audits, one that was not easily performed by an administrative claims database study as reported recently, 4 was our ability to clarify with the individual centre reporting pancreatitis cases to obtain the full details of the event. We also think that findings of gallstones, significant alcohol consumption or significant hypertriglyceridaemia are inherently not statistically-adjustable as attempted in the administrative claims database study; 4 there was either a different cause of pancreatitis or there was not! Further issues The audits do possess weaknesses with issues such as incom- plete recall or under-reporting of cases. We also believe that further studies are required to clarify on the issue of ‘sub- clinical pancreatitis’ or pancreatic mass expansion, with the background concern of pancreatic cancer. 3 However, we are concerned that a flawed conclusion of pancreatitis risk in a self-selected obese study population that shares many risk factors for the occurrence of pancreatitis has unwittingly bolstered alarm concerning what is otherwise a useful class of drug treatment for diabesity. KY Thong, 1 MBBS, FRACP REJ Ryder, 1 MD, FRCP 1 Department of Diabetes, Endocrinology and Lipids Metabolism, City Hospital, Birmingham, UK Acknowledgement We are grateful to the ABCD nationwide exenatide audit contributors who are listed in our previous paper on the audit which was published in this journal. 6 Declaration of interests KYT was employed as ABCD research fellow in the nation- wide ABCD GLP-1 audit programme by the Sandwell and West Birmingham Hospitals NHS Trust. This post was funded by ABCD with grants provided by Eli Lilly and Novo Nordisk. KYT has received speaker fees from Novo Nordisk and AstraZeneca and educational sponsorship from Eli Lilly, Novo Nordisk, Sanofi-Aventis and Takeda. REJR has received speaker fees, consultancy fees and/or educational sponsorships from a number of com- panies, including Bristol-Myers Squibb/AstraZeneca Alliance, Eli Lilly, GlaxoSmithKline, Novo Nordisk, Sanofi-Aventis and Takeda. References 1. Cohen D. Has pancreatic damage from glucagon suppressing diabetes drugs been underplayed? BMJ 2013;346:f3680. 2. Butler PC, et al. A critical analysis of the clinical use of incretin-based therapies: are the GLP-1 therapies safe? Diabetes Care 2013;36:2118–25. 3. Butler AE, et al. Marked expansion of exocrine and endocrine pancreas with incretin therapy in humans with increased exocrine pancreas dysplasia and the potential for glucagon-producing neuroendocrine tumors. Diabetes 2013;62:2595–604. 4. Singh S, et al. Glucagon like peptide 1-based therapies and risk of hospitalization for acute pancreatitis in type 2 diabetes mellitus: a population-based matched case- control study. JAMA Intern Med 2013;173:534–9. 5. Gale EAM. GLP-1 based agents and acute pancreatitis: drug safety falls victim to the three monkey paradigm. BMJ 2013;346:f1263. 6. Ryder REJ, et al., on behalf of the ABCD nationwide exenatide audit contributors. The Association of British Clinical Diabetologists (ABCD) nationwide exenatide audit Pract Diabetes Int 2010;27:352–7b. 7. Ryder REJ, et al., on behalf of the ABCD nationwide liraglutide audit contributors. Liraglutide pancreatitis: The ABCD nationwide liraglutide audit. Br J Diabetes Vasc Dis 2013; 13 (September). doi: 10.1177/1474651413502685. 310 PRACTICAL DIABETES VOL. 30 NO. 8 COPYRIGHT © 2013 JOHN WILEY & SONS Personal comment Was it really pancreatitis from GLP-1 receptor agonist therapy? Ken Thong, Bob Ryder
Transcript of Was it really pancreatitis from GLP-1 receptor agonist therapy?
We read with interest the recent publications alludingto the link between GLP-1 receptor agonist therapy(GLP-1RA) and the risk of acute pancreatitis.1–5 We
write to highlight that this seems at odds with our own expe-rience in two nationwide audits of GLP-1RA use, with thereported cases of pancreatitis being very rare in both audits.
The Association of British Clinical Diabetologists(ABCD) conducted audits on the use of exenatide twicedaily (2007–2009) and liraglutide (2009 – ongoing) toevaluate the safety and efficacy of these agents in real-lifeclinical practice. The structure and major findings of theexenatide audit, including the reported cases of acute pancreatitis, were published previously in this journal.6 Wehave also recently reported on the frequency of acute pancreatitis among patients in the liraglutide audit.7 Thepertinent feature of both audits was the specific enquiryinto the occurrence of pancreatitis in the audit query. Toour knowledge, both audits are as yet still the largestreported audits of GLP-1RA use in clinical practice (6717and 6010 patients, respectively). ABCD received grantsfrom Eli Lilly and Novo Nordisk for these audits, but theaudits were conducted independently of the pharma ceuti-cal companies, as was the reporting of pancreatitis casesfrom the individual participating sites.
As published previously, there were four cases of acutepancreatitis reported in the ABCD nationwide exenatideaudit. After scrutiny of each reported case, three cases hadalternative causes for the episode of pancrea titis – gall-stones, significant alcohol consumption and significanthypertriglyceridaemia. Only one case had no obvious alter-native cause.6 The audit monitored 3336 years of exposureto exenatide. With one case which might be related to exenatide therapy, this represents an incidence of 0.030per 100 patient years of exposure to exenatide. The equiv-alent finding in the ABCD nationwide liraglutide audit wasone possible related case among 3720 monitored years of exposure, representing an incidence of 0.027 per 100patient years of exposure to liraglutide.7
Key factorsA key lesson we learned from conducting the audits was thatthe correct adjudication of pancreatitis cases is extremelyimportant, especially when the frequency of an adverseevent is very low. There were three reported cases of abdom-inal pains in the exenatide audit with concerns for pancre-atitis but with subsequent normal amylase levels. These weredeemed not to be cases of pancreatitis. A particular strengthof the audits, one that was not easily performed by anadministrative claims database study as reported recently,4was our ability to clarify with the individual centre reportingpancreatitis cases to obtain the full details of the event. We also think that findings of gallstones, significant alcohol consumption or significant hypertriglyceridaemiaare inherently not statistically-adjustable as attempted in
the administrative claims database study;4 there was either a different cause of pancreatitis or there was not!
Further issuesThe audits do possess weaknesses with issues such as incom-plete recall or under-reporting of cases. We also believe thatfurther studies are required to clarify on the issue of ‘sub-clinical pancreatitis’ or pancreatic mass expansion, with thebackground concern of pancreatic cancer.3 However, weare concerned that a flawed conclusion of pancreatitis risk in a self-selected obese study population that sharesmany risk factors for the occurrence of pancreatitis hasunwittingly bolstered alarm concerning what is otherwise auseful class of drug treatment for diabesity.
KY Thong,1 MBBS, FRACPREJ Ryder,1 MD, FRCP1Department of Diabetes, Endocrinology and LipidsMetabolism, City Hospital, Birmingham, UK
AcknowledgementWe are grateful to the ABCD nationwide exenatide auditcontributors who are listed in our previous paper on theaudit which was published in this journal.6
Declaration of interestsKYT was employed as ABCD research fellow in the nation-wide ABCD GLP-1 audit programme by the Sandwell andWest Birmingham Hospitals NHS Trust. This post wasfunded by ABCD with grants provided by Eli Lilly andNovo Nordisk. KYT has received speaker fees from NovoNordisk and AstraZeneca and educational sponsorshipfrom Eli Lilly, Novo Nordisk, Sanofi-Aventis and Takeda.
REJR has received speaker fees, consultancy feesand/or educational sponsorships from a number of com-panies, including Bristol-Myers Squibb/AstraZenecaAlliance, Eli Lilly, GlaxoSmithKline, Novo Nordisk,Sanofi-Aventis and Takeda.
References1. Cohen D. Has pancreatic damage from glucagon suppressing diabetes drugs been
underplayed? BMJ 2013;346:f3680.2. Butler PC, et al. A critical analysis of the clinical use of incretin-based therapies: are
the GLP-1 therapies safe? Diabetes Care 2013;36:2118–25.3. Butler AE, et al. Marked expansion of exocrine and endocrine pancreas with incretin
therapy in humans with increased exocrine pancreas dysplasia and the potential forglucagon-producing neuroendocrine tumors. Diabetes 2013;62:2595–604.
4. Singh S, et al. Glucagon like peptide 1-based therapies and risk of hospitalization foracute pancreatitis in type 2 diabetes mellitus: a population-based matched case-control study. JAMA Intern Med 2013;173:534–9.
5. Gale EAM. GLP-1 based agents and acute pancreatitis: drug safety falls victim to thethree monkey paradigm. BMJ 2013;346:f1263.
6. Ryder REJ, et al., on behalf of the ABCD nationwide exenatide audit contributors. TheAssociation of British Clinical Diabetologists (ABCD) nationwide exenatide auditPract Diabetes Int 2010;27:352–7b.
7. Ryder REJ, et al., on behalf of the ABCD nationwide liraglutide audit contributors.Liraglutide pancreatitis: The ABCD nationwide liraglutide audit. Br J Diabetes VascDis 2013; 13 (September). doi: 10.1177/1474651413502685.
310 PRACTICAL DIABETES VOL. 30 NO. 8 COPYRIGHT © 2013 JOHN WILEY & SONS
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Was it really pancreatitis from GLP-1 receptoragonist therapy?Ken Thong, Bob Ryder
