Make Recommendation With Greater Caution

Letters to the Editor Acute and Chronic Pancreatitis by PD Dr. med. Georg Beyer, Prof. Dr. med. Albrecht Hoffmeister, Pia Lorenz MSc, PD Dr. med. Petra Lynen, Prof. Dr. med. Markus M. Lerch, and Prof. Dr. med. Julia Mayerle in Issue 29–30/2022

This article recommends the use of pregabalin for the treatment of chronic pancreatitis (1). This recommendation is surprising in view of the clinical absence of a neuropathic pain component and of an etiology of pain that, from a pathophysiological point of view, is not primarily neurogenic.

The sole basis for this recommendation, a Cochrane analysis (2), on the other hand, is far more cautious; there, only a single study of sufficient quality was found with which to justify a further assessment. However, that study was financed by the manufacturers of the original drug.

Ultimately, one finds here low- to at best moderate-quality evidence for a reduction in opiate requirements under high to very high doses (up to 600 mg/day) of pregabalin, doses that were also clearly relevant in terms of adverse events. The clinical relevance is deemed to be questionable.

It is not without reason that the official guideline on pancreatitis (3) is far more restrictive in this regard. The other studies referred to here were small, from one center, and with a 0 level of recommendation.

How the authors come to the conclusion that “Complementary to pain management, a treatment attempt with pregabalin can be considered (level of evidence: 2, strong consensus) (RCT: mean reduction of pain score 12%” is not clear to me from the presented evidence, all the more so since no pathophysiological rationale is given as to why a drug against neuropathic symptoms should be recommended in the absence of a neuropathic pain component and chronic inflammatory pain etiology.

DOI: 10.3238/arztebl.m2022.0327

Dr. med. Thorsten Nickel

Klinik für Innere Medizin II Gastroenterologie, Onkologie und Palliativmedizin, Imland Klinik Rendsburg, Germany

Conflict of interest statement

The author declare that no conflict of interest exists.

References

1. Beyer G, Hoffmeister A, Lorenz P, Lynen P, Lerch MM, Mayerle J: Clinical practice guideline: Acute and chronic pancreatitis. Dtsch Arztebl Int 2022; 119: 495–501

2. Gurusamy KS, Lusuku C, Davidson BR: Pregabalin for decreasing pancreatic pain in chronic pancreatitis. Cochrane Database Syst 2016; 2: CD011522

3. AWMF: Leitlinie zur Therapie der chronischen Pankreatitis. www.awmf.org/uploads/tx_szleitlinien/021-003l_S3_Pankreatitis_2022-04_01.pdf (last accessed on 20 Septmeber 2022).