A novel treatment protocol in severe acute pancreatitis: the first double blinded comparative trial to assess efficiency of omega 3 fatty acid infusion
DOI:
https://doi.org/10.18203/2349-2902.isj20214742Keywords:
Acute pancreatitis, Severe acute pancreatitis, Celepid, ω-3 PUFA infusion, ω-3 fatty acidAbstract
Background: For decades, the treatment of acute pancreatitis (AP) has been largely supportive. However, a therapeutic window for intervention using immune modulators exists between the onset of clinical symptoms and peak pro-inflammatory cytokine expression. Soybean oil derived ω-3 PUFA is shown to inhibit the formation of ω-6 PUFA derived pro-inflammatory eicosanoids and suppresses pro-inflammatory activity of nuclear transcription factors (NF-κβ); thus, bringing about a much-needed immune regulation, both locally and systemically. Our aim was to study the efficacy of ω-3 PUFA infusion in severe AP (SAP) and set a new treatment protocol.
Methods: This, first of its kind, doubled blinded randomised control trial was undertaken to assess the efficacy of early ω-3 PUFA supplementation in patients with predicted SAP by using serum amylase, serum lipase and C-reactive protein (CRP) with BISAP and Marshal scoring systems as markers for clinical outcome. 60 such patients were randomised into two groups: 30 were given ω-3 PUFA infusion and 30 were given a placebo. Chi square test and unpaired t test were used for comparison.
Results: ω-3 PUFA infusion was found to be highly significant (p<0.05) in bringing about clinical improvement, reduced progression of SAP, reduced hospital stay and prompt reversal of organ dysfunction and SIRS.
Conclusions: ω-3 PUFA infusion is the future for the treatment of patients with SAP. This drug is cheap and easily available, has no known side effects, reduces the morbidity and mortality, reduces the duration of hospital stay; thus, resulting in overall reduced medical expenditure.
References
Chiari H. On the self-digestion of the human pancreas. Z Heilk. 1896;17:69-96.
Bhatia M. Acute pancreatitis as a model of SIRS. Front Biosci. 2008;14:2042-50.
Jha R, Ma Q, Sha H, Palike M. Acute pancreatitis: A literature review. Med Sci Monit. 2009;15(7):147-56.
Norman J, M Franz, J Messina. Intrinsic production of proinflammatory cytokines by the pancreas during acute pancreatitis. Surg Forum. 1994;19.
Working Party of the British Society of Gastroenterology; Association of Surgeons of Great Britain and Ireland; Pancreatic Society of Great Britain and Ireland; Association of Upper GI Surgeons of Great Britain and Ireland. UK guidelines for the management of acute pancreatitis. Gut. 2005;54(3):1-9.
Norman JG, Franz MG, Fink GS, Messina J, Fabri PJ, Gower WR, et al. Decreased severity of experimental acute pancreatitis by pre-or post-treatment with interleukin-1 receptor antagonist. Gastroenterology. 1994;106(6):3-11.
Grewal HP, Din AM, Gaber L, Kotb M, Gaber AO. Amelioration of the physiologic and biochemical changes of acute pancreatitis using an anti-TNF-α polyclonal anti-body. Am J Surg. 1994;167(1):214-9.
Winslet M, Hall C, London NJ, Neoptolemos JP. Relation of diagnostic serum amylase levels to aetiology and severity of acute pancreatitis. Gut. 1992;33(7):982-6.
Heath DI, Cruickshank A, Gudgeon M, Jehanli A, Shenkin A, Imrie CW. Role of interleukin-6 in mediating the acute phase protein response and potential as an early means of severity assessment in acute pancreatitis. Gut. 1993;34(1):41-5.
Riché FC, Cholley BP, Laisné MC, Vicaut E, Panis YH, Lajeunie EJ, et al. Inflammatory cytokines, C reactive protein, and procalcitonin as early predictors of necrosis infection in acute necrotizing pancreatitis. Surgery. 2003;133(3):257-62.
Jiang C, Shiau Y, Ng K, Tan S. Serum interleukin-6, tumor necrosis factor alpha and C-reactive protein in early prediction of severity of acute pancreatitis. J Chin Med Assoc. 2004;67(9):442-6.
Pezzilli R, Billi P, Miniero R, Fiocchi M, Cappelletti O, Morselli-Labate AM, et al. Serum interleukin-6, interleukin-8, and β 2-Microglobulin in early assessment of severity of acute pancreatitis comparison with serum C-reactive protein. Dig Dis Sci. 1995;40(11):2341-8.
Meier R. Enteral fish oil in acute pancreatitis. Clin Nutr. 2005;24(2):169-71.
Mori TA, Beilin LJ. Omega-3 fatty acids and inflammation. Curr Atheroscler Rep. 2004;6(6):461-7.
Kang JX, Weylandt KH. Modulation of inflammatory cytokines by omega-3 fatty acids; Lipids in Health and Disease. Netherlands: Springer; 2008: 133-43.
Weylandt KH, Nadolny A, Kahlke N, Köhnke T, Schmöcker C, Wang J, et al. Reduction of inflammation and chronic tissue damage by omega-3 fatty acids in fat-1 transgenic mice with pancreatitis. Biochim Biophys Acta. 2008;1782(11):634-41.
Mayer K, Meyer S, Reinholz-Muhly M, Maus U, Merfels M, Lohmeyer J, et al. Short-time infusion of fish oil-based lipid emulsions, approved for parenteral nutrition, reduces monocyte proinflammatory cytokine generation and adhesive interaction with endothelium in humans. J Immunol. 2003;171(9):4837-43.
Weiss G, Meyer F, Matthies B, Pross M, Koenig W, Lippert H. Immunomodulation by perioperative administration of n-3 fatty acids. Br J Nutr. 2002;87(1):89-94.
Wang X, Li W, Li N, Li J. ω-3 fatty acids–supplemented parenteral nutrition decreases hyperinflammatory response and attenuates systemic disease sequelae in severe acute pancreatitis: a randomized and controlled study. J Parent Enter Nutr. 2008;32(3):236-41.
Rao SA, Kunte A. Assessment of immuno- modulatory effects of Ω-3 Pufa in patients of predicted severe acute pancreatitis using the positive predictive value of IL-6. IJSR. 2016;5:176-9.
Rudraiah HGM, Kalke SV, Desai A. A novel treatment protocol in acute pancreatitis- the first double blinded comparative trial of omega 3 fatty acid infusion versus octreotide. Int Surg J. 2018;5(12):4052-7.
Pearce CB, Sadek SA, Walters AM, Goggin PM, Somers SS, Toh SK, et al. A doubleblind, randomised, controlled trial to study the effects of an enteral feed supplemented with glutamine, arginine and omega-3 fatty acid in predicted acute severe pancreatitis. JOP. 2006;7(4):361-71.
Rao S, Kunte A. Assessment of efficacy of IV ω-3 PUFA supplementation in patients of predicted severe acute pancreatitis using the positive predictive value of Balthazar score within 48 hours of onset. Int J Med Res Rev. 2016;4(6):993-8.
Bhushan A, Bansal A, Shivram. A double blind comparative assessment of omega 3 fatty acid infusion and octreotide infusion in acute pancreatitis. EJMCM. 2020;7(8):5738-43.