From the Guidelines
Chronic pancreatitis treatment should prioritize a multidisciplinary approach, focusing on pain management, improving digestive function, and addressing complications, with the most recent evidence suggesting that surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis 1. The treatment of chronic pancreatitis involves several key components, including:
- Pain management, which typically begins with acetaminophen or NSAIDs like ibuprofen, progressing to weak opioids such as tramadol, and then stronger opioids like morphine or oxycodone for severe pain
- Antioxidant therapy, such as selenium, vitamin C, vitamin E, methionine, and beta-carotene, which may help reduce pain and inflammation
- Pancreatic enzyme replacement therapy (PERT), such as Creon or Zenpep, which is essential for digestive problems, typically taken with meals at doses of 25,000-40,000 lipase units per meal and 10,000-25,000 units with snacks
- Dietary modifications, including small, frequent, low-fat meals, avoiding alcohol completely, and limiting caffeine
- Endoscopic procedures to relieve ductal obstruction, and surgery options, including partial pancreatic resection or total pancreatectomy with islet autotransplantation for severe cases
- Blood sugar monitoring, as diabetes often develops, with a focus on individualized medical nutrition therapy, emphasizing regular monitoring and recording of blood glucose levels, and patient-specific meal plans to reduce hyperglycaemia and prevent hypoglycaemic events 1. It is also important to note that celiac plexus block should not be routinely performed for the management of pain due to chronic pancreatitis, but may be considered on a case-by-case basis for selected patients with debilitating pain in whom other therapeutic measures have failed 1. Additionally, the management of steatorrhoea with pancreatic enzyme replacement therapy is the mainstay of nutritional management, and early identification and treatment is key, as the presence of steatorrhoea, coupled with poor dietary intake, renders chronic pancreatitis patients at considerable risk for undernutrition, muscle depletion, and fat-soluble vitamin deficiency 1.
From the FDA Drug Label
The primary efficacy endpoint was the coefficient of fat absorption (CFA) in CREON and placebo treatment groups. A randomized, double-blind, placebo-controlled, parallel group study was conducted in 54 adult patients, aged 32 to 75 years, with exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatectomy (Study 4) The mean change in CFA from the run-in period to the end of the double-blind period in the CREON and placebo groups is shown in Table 3 Subgroup analyses of the CFA results showed that mean change in CFA was greater in patients with lower run-in period CFA values than in patients with higher run-in period CFA values.
The different ways to treat chronic pancreatitis include:
- Pancreatic enzyme replacement therapy: Using medications like CREON to replace the enzymes that the pancreas is not producing, as shown in Study 4 2.
- Dietary changes: Consuming a high-fat diet during treatment periods, as mentioned in the study.
- Medication dosage: Administering a specific dosage of CREON, such as 72,000 lipase units per main meal and 36,000 lipase units per snack, as directed in the study.
From the Research
Treatment Options for Chronic Pancreatitis
The treatment of chronic pancreatitis involves a multidisciplinary approach, including medical, endoscopic, and surgical therapy. The main goals of treatment are to control symptoms, prevent disease progression, and correct any complications.
- Endoscopic Therapy: Endoscopic therapy plays a significant role in the treatment of chronic pancreatitis, particularly in relieving obstruction of the pancreatic duct and bile duct, closing pancreatic duct leaks, and draining pseudocysts 3, 4, 5. It can be used as primary interventional therapy when medical measures fail or as a bridge to surgery.
- Pain Management: Pain control is central to the management of chronic pancreatitis. Strategies for pain management include the use of opioid medications, as well as non-pharmacologic and pharmacologic treatments such as gabapentinoids, which can help inhibit neurotransmitters involved in central sensitization 6, 7.
- Medical Management: Medical management of pain in chronic pancreatitis poses significant challenges due to the risk of long-term opioid use and the evolution of pain due to peripheral and central sensitization 7.
- Surgical Therapy: While not explicitly detailed in the provided studies, surgical therapy is mentioned as part of the multidisciplinary approach to treating chronic pancreatitis, especially when endoscopic therapy is not suitable or successful 3.
Specific Endoscopic Procedures
Endoscopic therapies for chronic pancreatitis include: