In Reply

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

We would like to thank our colleague for his critical comments as well as for the opportunity to set the record straight. The mechanism of pain development in chronic pancreatitis is variable (1). Neuropathic pain plays an important role in respect to the pathophysiology (2). Both in mouse models and in patients, morphological changes, such as neural hypertrophy and neuritis, as well as functional changes consistent with neuronal remodeling are present (2). Pain in chronic pancreatitis has not only a mechanical but also a local and a central nervous neuropathic component. This hampers selection of the optimal treatment, while at the same time opening up new treatment strategies and therapy approaches beyond the classical tools of pain treatment in gastrointestinal medicine (3). In regard to the recommendation and the evaluation of the evidence, the S3 guideline and abridged version in the Ärzteblatt are identical in terms of content and level of recommendation, although the explanation in the latter is brief due to the limited length of the text. The literature evaluation yields a high level of evidence according to 2011 OCEBM criteria, since randomized controlled studies are available. The methodological limitations put forward here are taken into consideration by weakening the recommendation to the open “can” formulation. The level of consensus merely reflects the voting behavior of the experts in the Delphi process and does not enable any direct conclusion regarding the strength of recommendation. At this point, we refer the reader to the guideline report of the German Society for Gastroenterology, Digestive and Metabolic Diseases (Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten, DGVS) (3). In view of a pancreatologist, pregabalin’s expansion of the drug spectrum is welcomed. For many patients with a chronic pain syndrome, interventional treatments are out of question due to the lack of morphological therapeutic goals or pre-existing comorbidities. An attempt at treatment with co-analgesics to strengthen the effect of “classic” analgesics is helpful and justifiable in the majority of patients and burdened with a low risk.

DOI: 10.3238/arztebl.m2022.0328

On behalf of the authors

Dr. med. Georg Beyer, Prof. Dr. med. Julia Mayerle

Medizinische Klinik und Poliklinik II, LMU Klinikum, München, Germany

Conflict of interest statement

Dr. Beyer received honoraria for continuing medical education events from the Falk Foundation e.V. and Akcea. He received honoraria for court-ordered expert opinions making reference to the content of the article. He is also spokesman for the Pancreas Working Group (AG Pankreas) of the DGVS, coordinator of the S3 guideline on pancreatitis of the DGVS, and a Member of the Board of the German Pancreas Club (Deutscher Pankreasclub e. V.).

Prof. Mayerle received honoraria for continuing medical education events from the Falk Foundation e. V. She is Chair of the UEG Scientific Committee and a Member of the Advisory Board of the DGVS as well as the Advisory Board of the Working Group of Pancreatectomized Patients (Arbeitskreis der Pankreatektomierten).

References

1. Drewes AM, Bouwense SAW, Campbell CM, et al.: Guidelines for the understanding and management of pain in chronic pancreatitis. Pancreatology 2017;17: 720–31.

2. Drewes AM, Kempeneers MA, Andersen DK, et al.: Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons! Gut 2019; 68:1343–51.

3. Lorenz P, Lynen Jansen P, Beyer G, Hoffmeister A, Lerch MM, Mayerle J: S3-Leitlinie Pankreatitis—Leitlinienreport der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS)—September 2021—AWMF Registernummer 021–003. Z Gastroenterol 2022; 60: e236–e47.

4. 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.