How to use Creon (Pancrelipase) in patients with mild pancreatic exocrine insufficiency?

From the Guidelines

For mild pancreatic insufficiency, Creon (pancrelipase) should be taken at a starting dose of at least 40,000 USP units of lipase during each meal in adults and one-half of that with snacks, as recommended by the AGA Clinical Practice Update on Exocrine Pancreatic Insufficiency 1.

Key Considerations

• The dose can be adjusted based on the meal size and fat content, with the primary goal of ensuring adequate digestion of lipids to meet macro-nutritional needs and reducing steatorrhea and intestinal symptoms 1.
• Creon should be taken during the meal to maximize mixing and digestion of nutrients, as it treats the meal, not the pancreas 1.
• The capsules should be swallowed whole with plenty of water, and not crushed or chewed, to protect the enzymes from stomach acid.
• If swallowing is difficult, the capsules can be opened and the contents sprinkled on a small amount of soft, acidic food like applesauce, then swallowed immediately without chewing.

Monitoring and Adjustment

• Regular follow-up with a healthcare provider is important to monitor effectiveness and adjust dosing as needed, with a focus on symptom control, particularly stool consistency, abdominal pain, and fat malabsorption symptoms.
• Routine supplementation monitoring of fat-soluble vitamin levels is also recommended, as part of the management of exocrine pancreatic insufficiency 1.

Dietary Considerations

• A low-moderate fat diet with frequent smaller meals is recommended, avoiding very-low-fat diets, as well as very high fiber diets, which may inhibit pancreatic enzyme replacement therapy 1.
• Dietary modifications should be individualized, taking into account the patient's nutritional needs and preferences, with the goal of achieving normal digestion and reducing symptoms.

From the Research

Using Creon in Mild Pancreatic Insufficiency

• Creon is a type of pancreatic enzyme replacement therapy (PERT) used to treat pancreatic exocrine insufficiency (PEI) 2.
• In mild pancreatic insufficiency, the digestive capacity of the gastrointestinal tract is partially impaired, and the coefficient of fat absorption (CFA) is slightly decreased 3.
• A staging system for exocrine pancreatic dysfunction (EPD) has been proposed, with Stage I (Mild) EPD characterized by a fecal elastase 1 (FE1) level of 100-200 mcg/gm, and non-pancreatic causes of steatorrhea are likely if present 3.
• In mild EPD, PERT may not be the best or first approach in management, and further study is needed to determine its clinical utility 3.
• Lifestyle modifications, such as reducing dietary fat intake, and exogenous pancreatic enzyme supplements like Creon, can help restore normal digestion and absorption of dietary nutrients in patients with exocrine pancreatic insufficiency (EPI) 4.
• The effectiveness of Creon in improving symptoms and CFA in patients with chronic pancreatitis and moderate to severe EPI has been demonstrated in clinical trials 5.
• Enzyme replacement therapy, including Creon, is currently the mainstay of treatment for nutrient malabsorption secondary to pancreatic insufficiency, and is safe with few side effects 6.