From the Guidelines
The primary treatment for pancreatic insufficiency is pancreatic enzyme replacement therapy (PERT), which should be taken during meals to maximize mixing and digestion of nutrients, with a starting dose of at least 40,000 USP units of lipase during each meal in adults and one-half of that with snacks. This treatment approach is based on the most recent and highest quality study available, which emphasizes the importance of PERT in improving outcomes in patients with exocrine pancreatic insufficiency (EPI) 1. The use of PERT has been shown to improve digestion of lipids, reduce steatorrhea and intestinal symptoms, and enhance nutritional status, ultimately leading to improved quality of life and reduced mortality.
Key aspects of PERT include:
- Taking prescription-strength pancreatic enzymes with every meal and snack
- Using delayed-release capsules containing lipase, amylase, and protease
- Common medications include Creon, Zenpep, and Pancreaze
- Adjusting the dose based on symptom control and nutritional status
- Monitoring fat-soluble vitamin levels and supplementing as necessary
- Considering a high-calorie, high-protein diet and proton pump inhibitors to reduce stomach acid
It is essential to note that over-the-counter commercially available pancreas enzyme replacements should not be used, as they are classified as dietary supplements only and lack standardization and regulation 1. Additionally, regular monitoring of nutritional status and symptom control is crucial to adjust therapy as needed, with measures including anthropomorphic assessments, serum biomarkers, and clinical evaluation 1.
The treatment response to PERT should be measured to ensure that adequate doses are being taken, and to assess the need for prescribing H2 receptor antagonist or proton pump inhibitors 1. By prioritizing PERT and monitoring its effectiveness, healthcare providers can significantly improve the morbidity, mortality, and quality of life outcomes for patients with pancreatic insufficiency.
From the Research
Primary Treatment for Pancreatic Insufficiency
The primary treatment for pancreatic insufficiency is pancreatic enzyme replacement therapy (PERT) 2, 3, 4, 5. This involves taking supplements that contain the enzymes needed for digestion, such as lipase, amylase, and protease.
Key Considerations for PERT
- The dosage of PERT should be individualized, with a typical starting dose of 20,000 to 40,000 units of lipase per meal 3, 4.
- Enteric-coated formulations are preferred, as they protect the enzymes from gastric acid and allow for coordinated emptying of enzymes and nutrients 3, 5.
- However, enteric-coated formulations may not always be effective, and alternative approaches such as adding non-enteric coated enzymes or using antisecretory drugs may be necessary 2, 5.
- The timing of enzyme administration is also important, with some studies suggesting that starting therapy with enteric-coated microbeads prior to the meal can help improve outcomes 2.
Monitoring and Adjusting Treatment
- Treatment should be monitored and adjusted based on symptoms and laboratory tests, such as fecal chymotrypsin levels 4.
- Patients with hyperacidity may benefit from adjuvant antisecretory therapy to reduce the duodenal acid load and improve enzyme activity 2, 5.
- Nutritional deficiencies associated with pancreatic insufficiency should also be addressed through a test and treat strategy 5.
Recent Studies and Developments
- A recent study demonstrated the bioavailability of a pancreatic extract product (Zenpep) in chronic pancreatitis patients with exocrine pancreatic insufficiency, highlighting the importance of enzyme delivery to the duodenum 6.
- Other studies have emphasized the need for individualized treatment approaches and the potential benefits of using non-enteric coated formulations in certain cases 2, 5.