From the Guidelines
The recommended treatment for Exocrine Pancreatic Insufficiency (EPI) is pancreatic enzyme replacement therapy (PERT), which should be taken during meals with an initial dose of at least 40,000 USP units of lipase per meal in adults and half that dose for snacks. Patients with EPI should take pancreatic enzyme supplements with every meal and snack, typically using products like Creon, Zenpep, or Pancreaze 1. The dosage can be adjusted based on the meal size and fat content, as well as symptom response.
Key Considerations for PERT
- PERT formulations are all derived from porcine sources and are equally effective at equivalent doses 1.
- Non-enteric-coated preparations require co-treatment with an acid-reducing agent to prevent acid denaturing of lipase and other digestive enzymes 1.
- The capsules should be swallowed whole with plenty of water during meals, not before or after. If patients have difficulty swallowing capsules, they can open them and sprinkle the contents on acidic foods like applesauce, but should not mix with alkaline foods.
Dietary Modifications and Monitoring
- Treatment should be accompanied by a nutritionist consultation, as patients may benefit from smaller, more frequent meals and a diet with moderate fat content rather than fat restriction 1.
- Acid-suppressing medications like proton pump inhibitors may be added if response to enzymes alone is inadequate, as they help prevent enzyme inactivation by stomach acid 1.
- Routine supplementation and monitoring of fat-soluble vitamin levels are appropriate, and dietary modifications include a low-moderate fat diet with frequent smaller meals and avoiding very-low-fat diets 1.
- Measures of successful treatment with PERT include reduction in steatorrhea and associated gastrointestinal symptoms; a gain of weight, muscle mass, and muscle function; and improvement in fat-soluble vitamin levels 1.
Importance of Monitoring and Follow-Up
- EPI should be monitored, and baseline measurements of nutritional status should be obtained, including body mass index, quality-of-life measure, and fat-soluble vitamin levels 1.
- A baseline dual-energy x-ray absorptiometry scan should be obtained and repeated every 1–2 years to assess for metabolic bone disease, which is common in patients with chronic pancreatitis 1.
From the FDA Drug Label
CREON is indicated for the treatment of exocrine pancreatic insufficiency in adult and pediatric patients. (1) The recommended treatment for Exocrine Pancreatic Insufficiency (EPI) is pancrelipase (2).
- Key points:
- Pancrelipase is indicated for the treatment of EPI in adult and pediatric patients.
- The safety and effectiveness of pancrelipase for the treatment of EPI have been established in pediatric patients (2).
From the Research
Treatment for Exocrine Pancreatic Insufficiency (EPI)
The recommended treatment for EPI includes:
- Pancreatic enzyme replacement therapy (PERT) as the standard treatment 3, 4, 5, 6, 7
- Support to stop smoking and alcohol consumption 4
- Dietary consultation 4
- A structured follow-up of nutritional status and the effect of treatment 4
Pancreatic Enzyme Replacement Therapy (PERT)
- PERT dosing guidelines vary widely across disease types 3
- Starting doses are typically 40,000-50,000 units of lipase/meal with increases of up to two to three times this amount before pursuing additive therapies 3, 4
- The dose should be in proportion to the fat content of the meal 4
- PERT is administered in the form of enteric-coated minimicrospheres during meals 4