Adalimumab-related hypertriglyceridemia and acute pancreatitis

To the Editor, We read with interest the recent article by Kalra et al.1 published in your esteemed journal. Based on our recent experience on hypertriglyceridemia-related pancreatitis, we would like to make a few additional comments which we believe could add to the fund of knowledge of QJM readers. A 31-year-old man with past medical history of alcohol use disorder, psoriasis on adalimumab for the past 4 months presented to emergency room for abdominal pain of 2 days duration. Laboratory results suggested blood alcohol levels of 22 mg/dl, high lipase levels (140 U/l) and high triglyceride levels (4425 mg/dl). Computed tomography of abdomen showed evidence of severe peripancreatic inflammatory changes, predominantly involving pancreatic head with peripancreatic free fluid (Figure 1). She was given 3 l of fluid bolus of normal saline 0.9% and initiated on intravenous (IV) insulin drip @ 0.1 units/kg/h which was continued for next 24 h until triglyceride level came down below 500 mg/dl (Figure 2). Dextrose/normal saline was continued for next few days until he started tolerating oral diet. For prevention of recurrence of hypertriglyceridemia, patient was initiated on oral gemfibrozil 600 mg twice daily and counseled for dietary modification. Computed tomography abdomen showing evidence of pancreatic tissue inflammation suggestive of pancreatitis. Computed tomography abdomen showing evidence of pancreatic tissue inflammation suggestive of pancreatitis. Management of hypertriglyceridemia with graphical trend of blood glucose and triglyceride values with IV fluids and insulin drip. Management of hypertriglyceridemia with graphical trend of blood glucose and triglyceride values with IV fluids and insulin drip. First approved in 2002, Adalimumab is used to treat rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and few other autoimmune and rheumatological disorders. With regards to gastrointestinal side effects, adalimumab is well known to cause hepatitis B virus reactivation. However, reports on hypertriglyceridemia and acute pancreatitis are sparse. Damiano et al. reported a case of Infliximab-induced severe hypertriglyceridemia and eruptive xanthomas.2 Similarly, Etanercept-related hypertriglyceridemia was reported by Gonzalez et al.3 It is important to remember that before relating hypertriglyceridemia to anti-tumor necrosis factor-alpha (TNFα) agents, the other common causes should be ruled out. In our case, though the patient was alcoholic, but it is likely that the severe hypertriglyceridemia and subsequent acute pancreatitis were related to adalimumab. Recently, we also reported a case of alcohol-induced hypertriglyceridemia leading to acute pancreatitis.4 It is hypothesized that TNFα blockade could potentially increase production of other cytokines. This may affect lipogenesis with resultant increase in hepatic synthesis of triglycerides. Table 1 briefly mentions the details of our experience with two hypertriglyceridemia-related pancreatitis cases and Kalra et al.’s case. Details of the patients with hypertriglyceridemia-related acute pancreatitis Details of the patients with hypertriglyceridemia-related acute pancreatitis To our best knowledge, there are only few reports on anti-TNF-a therapy related with acute pancreatitis.5,6 Hence through this report, we endorse for increased observance for dyslipidemia in patients on anti-TNF-a therapy. This becomes more crucial especially in those with a personal or family history of hypertriglyceridemia or has other comorbidities like alcohol abuse which makes them more prone to develop hypertriglyceridemia. Newer biological agents and immunotherapies are associated with rare and complex adversities and awareness about them is advisable.7,8,9 Conflict of interest. None declared.