C0078 - Nirmatrelvir/ritonavir - A New Culprit of Acute Pancreatitis

Simon P. Abi-Saleh, MD¹, Amanda Abi Doumet, MD¹, Radhika Ayyagari, MD^2
1UConn Health, Farmington, CT; ²Saint Francis Hospital, Trinity Health of New England, Hartford, CT

Introduction: Nirmatrelvir/ritonavir is a new medication approved for the treatment of COVID-19 infection. It prevents viral replication by inhibiting the SARS-CoV-2 main protease. While mild adverse effects were described, including dysgeusia, diarrhea, hypertension and myalgia1, there were no reported cases of pancreatitis.

Case Description/Methods: An 81-year-old female with a past medical history of hypertension and COPD presented to the hospital complaining of abdominal pain and nausea for one day. She had no history of alcohol, tobacco or marijuana use, recent travel, or trauma. Her medications included lisinopril and prednisone, and she had completed a 5-day course of nirmatrelvir/ritonavir for the treatment of COVID-19 infection two days prior to presentation. On abdominal exam, she had left upper and lower quadrant tenderness. Blood tests revealed an amylase of 1333 U/L, lipase of 3779 U/L, triglycerides of 297 mg/dL and calcium of 8.7 mg/dL. CT scan revealed an indurated pancreatic body and tail with peripancreatic fluid along the paracolic gutter. Ultrasound of the abdomen and MRCP did not reveal any acute findings. IgG subclasses 1-4 were normal.

Discussion: According to the revised Atlanta criteria, the patient had clinical findings consistent with acute pancreatitis. Common causes such as gallstone, alcohol, autoimmune and hypertriglyceridemia-induced pancreatitis were ruled out. There were no masses or structural abnormalities on imaging that might have explained her diagnosis. There have been at least two reported cases of lisinopril and prednisone induced pancreatitis, however according to Badalov et al.2 both of these medications are class III drugs that lack any rechallenge in the literature. Moreover, the patient had been taking these medications for many years, making them an unlikely cause of the presenting diagnosis. There are no reports of nirmatrelvir/ritonavir associated pancreatitis or known pharmacologic interaction with her home medications, and a meta-analysis conducted by Babajide et al.3 revealed no association between acute pancreatitis and COVID-19 infection. Given the negative findings stated above and the recent initiation of a new medication, nirmatrelvir/ritonavir was the likely cause of acute pancreatitis.

1. 
   Lamb YN, Nirmatrelvir Plus Ritonavir: First Approval, 2022, 585-591
   
   


2. 
   Badalov N et al, Drug-induced acute pancreatitis: an evidence-based review, 2007, 648-661
   
   


3. 
   Babajide OI et al, COVID-19 and acute pancreatitis: a systematic review, 2022, 231-235
   
   

Disclosures:


Simon P. Abi-Saleh, MD¹, Amanda Abi Doumet, MD¹, Radhika Ayyagari, MD². C0078 - Nirmatrelvir/ritonavir - A New Culprit of Acute Pancreatitis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.