Highlights
The PAMORA-RAP trial provides evidence for the first pharmacological intervention to prevent recurrent acute pancreatitis. Key highlights include:
- Naldemedine (0.2 mg daily) was associated with a 46% reduction in the risk of acute pancreatitis recurrence compared to placebo (HR 0.54; 95% CI, 0.29-1.01; p = 0.05).
- Participants who remained on treatment for at least one year experienced a statistically significant reduction in recurrence risk (HR 0.49; 95% CI, 0.24-0.97; p = 0.04).
- The treatment was safe and well-tolerated, with no significant differences in gastrointestinal adverse events or quality-of-life scores compared to the placebo group.
The Clinical Challenge of Recurrent Acute Pancreatitis
Recurrent acute pancreatitis (RAP) represents a significant clinical challenge characterized by repeated episodes of pancreatic inflammation. For patients, RAP is not only a source of severe pain and frequent hospitalizations but also a major risk factor for the development of chronic pancreatitis, pancreatic exocrine insufficiency, and type 3c diabetes mellitus. Despite its high disease burden, the therapeutic landscape for RAP has remained stagnant for decades.
Current management focuses primarily on identifying and mitigating underlying etiologies, such as gallstones, hypertriglyceridemia, or alcohol consumption. However, in many cases, the etiology remains idiopathic or involves complex factors like sphincter of Oddi dysfunction. Currently, no pharmacological agents are approved specifically for the prevention of RAP, leaving a significant unmet medical need for clinicians and patients alike.
The PAMORA-RAP Trial: Study Design and Methodology
The PAMORA-RAP trial (NCT04966559) was a multicentre, double-blinded, placebo-controlled randomized trial conducted at four specialized pancreatitis referral centres in Denmark. The study aimed to evaluate the efficacy and safety of naldemedine, a peripherally acting μ-opioid receptor antagonist (PAMORA), in reducing the risk of acute pancreatitis recurrence.
Population and Randomization
The trial enrolled 74 participants aged 18 to 75 years who had a documented history of recurrent acute pancreatitis. Notably, the study included patients both with and without a concomitant diagnosis of chronic pancreatitis, reflecting the real-world spectrum of patients seen in clinical practice. Participants were randomized in a 1:1 ratio to receive either 0.2 mg of naldemedine daily or a matching placebo for a period of up to 12 months.
Endpoints and Definitions
The primary outcome was the recurrence of acute pancreatitis, strictly defined according to the Revised Atlanta Criteria (requiring at least two of the following: characteristic abdominal pain, serum amylase or lipase levels at least three times the upper limit of normal, or characteristic findings on cross-sectional imaging). Secondary outcomes were comprehensive, including the frequency of pain flares, gastrointestinal symptoms (assessed via the Gastrointestinal Symptom Rating Scale), quality of life (EORTC QLQ-C30), and the development of new-onset diabetes or pancreatic exocrine insufficiency.
Key Findings: Efficacy and Statistical Significance
Over a median follow-up period of 365 days, the trial yielded promising results regarding the preventive potential of naldemedine.
Primary Outcome Analysis
In the intention-to-treat analysis, participants in the naldemedine group (n=36) demonstrated a numerically lower risk of recurrence compared to the placebo group (n=38). The hazard ratio (HR) was 0.54 (95% CI, 0.29-1.01), with a p-value of 0.05. While the p-value sits at the threshold of traditional statistical significance, the clinical effect size—a nearly 50% reduction in risk—is highly relevant for this patient population.
The Impact of Treatment Adherence
A pre-specified subgroup analysis focused on participants who maintained treatment for at least one year. In this cohort, the benefit of naldemedine became even more pronounced and reached statistical significance, with a hazard ratio of 0.49 (95% CI, 0.24-0.97; p = 0.04). This suggests that the protective effect of naldemedine may be cumulative or require consistent therapeutic levels to optimize outcomes.
Secondary Efficacy and Metabolic Outcomes
Interestingly, the study did not find significant differences between the two groups regarding secondary outcomes such as the frequency of pain flares or quality-of-life scores. Furthermore, there were no significant differences in the incidence of new-onset diabetes or pancreatic exocrine insufficiency during the study period, although the 12-month follow-up may be too short to observe definitive changes in these long-term complications.
Safety and Tolerability
Safety is a paramount concern for any long-term preventive therapy. Naldemedine, which is traditionally used to treat opioid-induced constipation, was exceptionally well-tolerated in this study population. There were no significant differences in the overall rate of adverse events between the naldemedine and placebo groups. Specifically, gastrointestinal symptoms—often a concern with opioid antagonists—did not differ significantly, suggesting that the 0.2 mg dose is suitable for long-term maintenance in patients with RAP.
Expert Commentary: Mechanistic Insights and Clinical Implications
The rationale for using a peripherally acting μ-opioid receptor antagonist in RAP is rooted in the complex physiology of the biliary and pancreatic ducts. The μ-opioid receptors are prevalent in the gastrointestinal tract and, crucially, in the sphincter of Oddi. Endogenous or exogenous opioids can induce contraction of the sphincter of Oddi, increasing intraductal pressure and potentially triggering pancreatitis.
By blocking these peripheral receptors without crossing the blood-brain barrier, naldemedine may stabilize pancreatic ductal pressure and improve the flow of pancreatic enzymes, thereby reducing the mechanical and inflammatory triggers of an acute attack. This mechanism is particularly intriguing for patients whose recurrence may be linked to subclinical sphincter of Oddi dysfunction or opioid-induced biliary stasis.
However, clinicians must interpret these results with caution. The small sample size (n=74) and the borderline p-value for the primary endpoint indicate that while the signal is strong, it requires validation. The study’s strengths include its rigorous double-blind design and the use of the Revised Atlanta Criteria, which ensures the reliability of the diagnosis of recurrence.
Conclusion and Future Directions
The PAMORA-RAP trial represents a significant step forward in the search for a pharmacological preventive strategy for recurrent acute pancreatitis. Naldemedine appears to be a safe and potentially effective option, especially for patients capable of long-term adherence. While these findings are encouraging, they should be viewed as hypothesis-generating. A larger, phase 3 confirmatory trial is essential to definitively establish naldemedine’s role in the standard of care for RAP and to identify which patient phenotypes (e.g., those with idiopathic RAP vs. those with early-stage chronic pancreatitis) benefit the most from this intervention.
Funding and Clinical Trial Information
This study was supported by grants from relevant Danish health authorities and research foundations. ClinicalTrials.gov Identifier: PAMORA-RAP: NCT04966559.
References
1. Cook ME, Knoph CS, Davidsen L, et al. Naldemedine for the Prevention of Recurrent Acute Pancreatitis: A Randomised, Double-Blind, Placebo-Controlled Trial. United European Gastroenterol J. 2026;14(1):e70178. doi: 10.1002/ueg2.70178.
2. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111.
3. Guda NM, Tringali A, Talukdar R, et al. Management of Recurrent Acute Pancreatitis: An International Survey and Clinical Practice Algorithm. J Clin Gastroenterol. 2022;56(3):e183-e191.
