What are the treatment guidelines for chronic pancreatitis?

From the Guidelines

The treatment for chronic pancreatitis should prioritize pancreatic enzyme replacement therapy (PERT) with at least 40,000 USP units of lipase during each meal, along with a low-moderate fat diet and frequent smaller meals, as recommended by the most recent guidelines 1. The management of chronic pancreatitis involves a multifaceted approach that includes pain management, addressing pancreatic insufficiency, and lifestyle modifications.

• Pain control typically begins with acetaminophen or NSAIDs, progressing to weak opioids like tramadol, and then stronger opioids such as morphine or oxycodone for severe pain.
• Adjuvant medications including pregabalin (150-300 mg daily), gabapentin (900-1800 mg daily), or tricyclic antidepressants like amitriptyline (10-75 mg at bedtime) can help manage neuropathic pain.
• For pancreatic enzyme insufficiency, PERT is essential, with typical dosing of 25,000-40,000 lipase units per meal and 10,000-25,000 units with snacks, taken just before or during meals 1.
• Fat-soluble vitamin supplementation (A, D, E, K) is often necessary, as recommended by the guidelines 1.
• Nutritional support includes a low-fat diet (less than 30% of calories from fat), frequent small meals, and adequate hydration, as suggested by the ESPEN guidelines on clinical nutrition in acute and chronic pancreatitis 1.
• Complete alcohol abstinence is crucial as continued consumption accelerates pancreatic damage, and smoking cessation is equally important as it independently worsens disease progression.
• Blood glucose monitoring and diabetes management may be necessary as endocrine insufficiency develops, and endoscopic or surgical interventions may be considered for complications like pseudocysts, ductal strictures, or intractable pain. The most recent guidelines from the AGA clinical practice update on the epidemiology, evaluation, and management of exocrine pancreatic insufficiency provide the best practice advice for the management of chronic pancreatitis, emphasizing the importance of PERT and lifestyle modifications 1.

From the Research

Treatment Guidelines for Chronic Pancreatitis

The treatment guidelines for chronic pancreatitis involve a combination of lifestyle modifications, medication, and surgical interventions.

• Lifestyle modifications include cessation of alcohol and tobacco use, and eating small, frequent, low-fat meals 2, 3.
• Medications such as analgesics, including nonsteroidal anti-inflammatory drugs and weak opioids, can provide pain relief 3, 4.
• Pancreatic enzyme supplements and antioxidants may also be beneficial in controlling symptoms 3, 5.
• Surgical interventions, such as decompressive surgical procedures or resection procedures, may be indicated for patients with large duct disease or pancreatic head enlargement 2.
• Endoscopic therapy, including endoscopic retrograde cholangiopancreatography (ERCP) or surgical drainage procedures, may be used to treat symptomatic strictures, stones, and pseudocysts 2, 3.

Management of Pain in Chronic Pancreatitis

Pain management is a crucial aspect of treating chronic pancreatitis.

• Strict abstinence from alcohol is the first step in managing chronic pancreatic pain 4.
• Symptomatic treatment with analgesics, such as acetaminophen, non-steroidal anti-inflammatory drugs, and eventually opioids, may be necessary 4.
• A multidisciplinary approach to pain management, tailoring therapeutic options to individual patient needs, is recommended 4.

Nutrition Therapy in Chronic Pancreatitis

Nutrition deficiencies are common in chronic pancreatitis, and nutrition therapy is an essential part of management.

• The etiology of nutrition deficiencies is multifactorial, including exocrine and/or endocrine dysfunction, significant abdominal pain, and increased metabolic activity 6.
• Oral and pancreatic enzyme supplementation can manage nutrition deficiencies in most patients, while some may require enteral tube feeding or parenteral feeding 6.
• Current research areas include identifying patients at risk for nutrition deficiencies, optimizing feeding regimens, and exploring islet cell autotransplantation 6.