Citation Nr: 21001363 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 18-07 361 DATE: January 7, 2021 REMAND Entitlement to service connection for pancreatitis is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from July 1966 to July 1969, including service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) from an August 2017 rating decision of a VA Regional Office (RO), which, in pertinent part, denied service connection for pancreatitis. The Veteran filed a timely notice of disagreement received by VA in September 2017. In January 2018, the RO issued a statement of the case. In his February 2018 VA Form 9, Appeal to Board of Veterans’ Appeals the Veteran requested a Board Central Office Hearing. In November 2020, the Veteran submitted a request to withdraw his hearing. As such the Board finds that the prior hearing request is withdrawn. Entitlement to service connection for pancreatitis The Veteran contends that his current pancreatitis disability was proximately caused or by aggravated his service-connected diabetes mellitus (DM). See, e.g., September 2017 Notice of Disagreement. The Veteran is currently in receipt of service connection for DM from May 2001 forward. The Board finds that a remand is warranted for additional development. VA and private treatment records have been associated with the claims file. During the appeal period, treatment records note that there were some inconsistencies as to whether the Veteran has a current diagnosis of chronic pancreatitis. A May 2017 letter from a private physician to the Veteran states that a recent CT scan shows calcifications in the pancreas which would suggest the possibility of chronic pancreatitis. A report from the CT scan is of record, and finds, in pertinent part, that there were multiple foci of calcification within the pancreas, likely representing sequela of chronic pancreatitis. In July 2017, the Veteran was afforded a VA examination. The examiner explained that the CT reports revealed a possibility that the Veteran had chronic pancreatitis, but the Veteran was not, at the time of the VA examination, actually diagnosed as having pancreatitis. The examiner explained that while there may be some association of DM to pancreatitis, it could not be stated as a probability of 50 percent or greater that DM was the cause of chronic pancreatitis. The examiner noted that possible etiological issues associated with chronic pancreatitis, according to medical literature, included: alcohol abuse, genetic causes, ductal obstruction, tropical pancreatitis, systemic disease such as systemic lupus erythematosus, hypertriglyceridemia, possibly hyperparathyroidism, autoimmune pancreatitis, or idiopathic pancreatitis. DM was not a listed causative agent. The VA examiner opined that, if the Veteran did have chronic pancreatitis, the CT findings of calcifications indicated the most likely cause was either ductal obstruct However, January 2018 private treatment records from Dr. R.R. indicate that the Veteran had recently been diagnosed as having chronic pancreatitis. VA and private treatment records note during the appeal period the Veteran has been prescribed sitagliptin phosphate 100 milligrams daily to treat his DM. Private treatment records indicate that the Veteran was prescribed Januvia to treat his DM as early as January 2017. Januvia is the brand name for sitagliptin. An August 2017 VA treatment note indicates that the Veteran was being prescribed sitagliptin by a non-VA physician. According to the note, the most common side effect of sitagliptin is pancreatitis. Also, of record are private treatment records from Dr. J.G., M.D. An August 2017 record from Dr. J.G. shows the Veteran’s calcified spots in the pancreas were chronic and permanent, but there was no evidence of severe pancreas insufficiency—though there may have been some mild insufficiency. Dr. J.G. discussed enzyme replacements with medications such as CREON and provided the Veteran with a sample. Blood testing for autoimmune pancreatitis was negative, imaging showed no mass lesions in the pancreas, and stool testing for pancreas insufficiency showed moderate to slight pancreatic exocrine insufficiency. Dr. J.G. noted that since the Veteran was last seen, he stopped taking Januvia because of his chronic pancreatitis. VA treatment records from October 2017 note that the Veteran was recently diagnosed as having chronic pancreatitis by an outside provider and that the medication Januvia was a common cause. The primary diagnoses included, in pertinent part, history of pancreatitis, on CREON, “likely due to use of Januvia.” Private treatment records in January 2018 private from Dr. R.R. indicate that the Veteran had recently been diagnosed as having chronic pancreatitis. Januvia was still included in the list of current medications prescribed to treat the Veteran’s DM. The Board finds that a remand is necessary to obtain a supplemental VA opinion to fully address secondary service connection. VA and private treatment records note a diagnosis of pancreatitis during the appeal and have suggested a potential causative relationship to the Veteran’s service-connected diabetes mellitus type II. Specifically, the Board finds that a remand is warranted for a supplemental VA opinion. The July 2017 VA examiner failed to fully consider whether the Veteran’s pancreatitis was caused by or aggravated by taking Januvia. As such a remand is warranted for a supplemental VA opinion. The matter is REMANDED for the following action: Provide an appropriate clinician access to the Veteran’s claims folder for the purposes of obtaining a medical opinion on the nature and etiology of the Veteran’s current pancreatitis disability. The need for an examination is left to the discretion of the clinician. The clinician should provide an opinion as to whether: Is it at least as likely as not (50% or greater probability) that the Veteran’s pancreatitis was either (a) caused by or (b) aggravated by use of Januvia (sitagliptin) in association with the Veteran’s service-connected diabetes mellitus? In providing the rationale for this opinion, the clinician should consider the relevant evidence of record, to include: (a) private and VA treatment records indicating the Veteran was prescribed Januvia to treat diabetes mellitus in August 2016 or earlier; (b) CT scans, reports, and summaries from November 2016 and May 2017; (c) private and VA treatment records from October 2017, August 2017, and February 2018 indicating a potentially causative relationship between Januvia and pancreatitis. Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. K.R. Kardian Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Hillan Sosa, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.