Texas Tech University Health Sciences Center Amarillo, TX, United States
Muhammad Kashif Amin, MD1, Muhammad Atif Khan, MD1, Umer Farooq, MD2, Asma Zakir, MBBS3, Faiza Humayun Khan, MBBS4, Shafqat Jabeen, MBBS5, Kaylee Shepherd, MD1 1Texas Tech University Health Sciences Center, Amarillo, TX; 2Loyola Medicine/MacNeal Hospital, Berwyn, IL; 3King Edward Medical University, Amarillo, TX; 4University of Health Sciences, Amarillo, TX; 5University of Health Sciences, Lahore, Punjab, Pakistan
Introduction: Tamoxifen is a selective estrogen receptor modulator used in the treatment of estrogen and progesterone receptor-positive breast cancer. It affects lipoprotein metabolism resulting in hypertriglyceridemia through increased synthesis of VLDL and inhibiting activity of lipoprotein lipase and hepatic triglyceride lipase. Herein, we describe a case of tamoxifen induced marked hypertriglyceridemia leading to acute pancreatitis.
Case Description/Methods: A 62-year-old Hispanic female with a medical history significant for diabetes mellitus, hypertension, dyslipidemia, hyperthyroidism, and carcinoma of the right breast presented to ED with severe epigastric pain. History was negative for alcoholism, gallstones, and steroid use. Invasive ductal carcinoma breast ( ER+, PR+, HER-2/neu–, stage T1bN0M0) was managed 3 years ago with lumpectomy, adjuvant radiotherapy, followed by hormonal therapy with tamoxifen 20 mg. Imaging showed peripancreatic inflammation without necrosis, normal biliary tract, without evidence of cholelithiasis. Serum chemistry showed lipase 14,258 IU/L, corrected calcium 9.4 mg/dL, triglyceride 20,344 mg/dL, cholesterol 1,404 mg/dL, unmeasurable LDL levels, VLDL 4,069 mg/dL, blood glucose 230 mg/dL, A1c 9.6% and TSH 3.25 mcIU/mL. She was managed with insulin infusion, IV fluids, and analgesics for hypertriglyceridemia-induced acute pancreatitis. A retrospective review of records showed normal triglyceride levels two years ago. Tamoxifen was suspended after discussing with the oncologist and Gemfibrozil was initiated.
Discussion: Tamoxifen is a widely prescribed hormonal therapy for breast carcinoma for extended durations. It has an estrogenic effect on lipid metabolism resulting in high triglyceride and chylomicron levels. Elevated triglyceride levels accumulate in pancreatic capillaries resulting in ischemia and necrosis. The level needed to precipitate acute pancreatitis ranges from 900-7000 mg/dL. The time of onset from initiation of Tamoxifen ranges from 6 months to many years. Furthermore, hypertriglyceridemia induced acute pancreatitis is more prevalent in patients with concomitant diabetes and dyslipidemia. Withdrawal of Tamoxifen results in reported normalization of lipid levels. Therefore, it is prudent to monitor lipid levels pre-treatment and periodically during the treatment in both populations with or without contributing co-morbidities.
Muhammad Kashif Amin indicated no relevant financial relationships.
Muhammad Atif Khan indicated no relevant financial relationships.
Umer Farooq indicated no relevant financial relationships.
Asma Zakir indicated no relevant financial relationships.
Faiza Humayun Khan indicated no relevant financial relationships.
Shafqat Jabeen indicated no relevant financial relationships.
Kaylee Shepherd indicated no relevant financial relationships.
Muhammad Kashif Amin, MD1, Muhammad Atif Khan, MD1, Umer Farooq, MD2, Asma Zakir, MBBS3, Faiza Humayun Khan, MBBS4, Shafqat Jabeen, MBBS5, Kaylee Shepherd, MD1. P2201 - Tamoxifen-Induced Hypertriglyceridemia Leading to Acute Pancreatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.