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340 Pancreatitis
(which lacks effects on the sphincter of Oddi) is more efficacious and causes
fewer GI motility side effects than PO morphine. 4,8
There is conflicting information as to the role of NSAIDs in treating pancreatitis
pain. One expert consensus panel included NSAIDs as a first-line
treatment for flares of chronic pancreatitis. 9 In a study with potential relevance
to the ED setting, an RCT in outpatients with chronic pancreatitis
found that indomethacin (50 mg PR every 12 h) provided effective analgesia
and had an opioid-sparing effect. 10 However, the human-subjects literature
on pancreatitis and NSAIDs (including those agents with COX-2 selectivity)
consists primarily of sporadic reports of NSAID-induced pancreatitis. 11 Risk of
this rare but concerning complication tempers enthusiasm for ED use of
NSAIDs for pancreatitis. The COX-2 selective NSAID misoprostol has been
described as useful in chronic pancreatitis, but comprehensive reviews of
available evidence find insufficient data to support ED use of COX-2 selective
NSAIDs. 12,13
The cholecystokinin (CCK)-receptor antagonists proglumide and loxiglumide
appear to be effective in ameliorating pain from acute exacerbations of
pancreatitis. One study demonstrated improvement in both subjective and
objective (laboratory) parameters. 14 Another trial found that multiple oral
regimens of loxiglumide improved acute pancreatitis symptoms; a 600 mg/day
dosage improved pain in over half of the patients. 15 There may be an occasional
ED role for CCK-receptor antagonists for pancreatitis pain that is
refractory to opioids. The ED physician’s lack of familiarity with CCK-receptor
antagonists will usually mean proglumide or loxiglumide are reserved for
use after consultation with physicians more accustomed to these agents.
Other drugs for which any pancreatitis analgesia role lies outside the ED
include the viscosity-lowering agent bromhexine, the platelet-activating factor
receptor antagonist lexipafant, and the protease inhibitors aprotinin or
gabexate. 16,17 There are varying degrees of evidentiary support for these
agents’ efficacies, but none of the applicable data supports their early use in
the acute care setting.
Given potent inhibitory effects on pancreatic secretion, somatostatin and
its analog octreotide have been studied for use in pancreatitis. Prophylactic
somatostatin may reduce the rate of pancreatitis after endoscopic retrograde