From the Guidelines
The primary treatment for pancreatic insufficiency indicated by low fecal elastase levels 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 with snacks, as recommended by the most recent guidelines 1.
Key Considerations for PERT
- PERT formulations are all derived from porcine sources and are equally effective at equivalent doses 1.
- The choice of PERT formulation may depend on factors such as cost, patient preference, and insurance coverage.
- Acid-suppressing medications like proton pump inhibitors (e.g., omeprazole 20-40mg daily) may be added if symptoms persist, as they help prevent enzyme degradation in the stomach 1.
Dietary Modifications
- Dietary modifications are also important, including consuming smaller, more frequent meals and ensuring adequate nutrition with particular attention to fat-soluble vitamins (A, D, E, K) which may require supplementation 1.
- A low-moderate fat diet with frequent smaller meals and avoiding very-low-fat diets is recommended 1.
Monitoring and Adjustment
- The dosage of PERT should be adjusted based on the meal size and fat content, and symptom response 1.
- Routine supplementation and monitoring of fat-soluble vitamin levels are appropriate, and measures of successful treatment with PERT include reduction in steatorrhea and associated gastrointestinal symptoms, weight gain, and improvement in fat-soluble vitamin levels 1.
Importance of Treatment
- Untreated pancreatic insufficiency can result in complications related to fat malabsorption and malnutrition, having a negative impact on quality of life 1.
- PERT is essential for managing pancreatic insufficiency and improving outcomes in patients with cystic fibrosis and other conditions associated with exocrine pancreatic insufficiency 1.
From the FDA Drug Label
INDICATIONS AND USAGE CREON is indicated for the treatment of exocrine pancreatic insufficiency in adult and pediatric patients. (1) The treatment for low fecal elastase levels indicating potential pancreatic insufficiency is pancrelipase (CREON) 2.
- Key points:
- Pancrelipase is indicated for the treatment of exocrine pancreatic insufficiency.
- Low fecal elastase levels are a marker of pancreatic insufficiency.
- Pancrelipase (CREON) is a suitable treatment option for patients with low fecal elastase levels.
From the Research
Treatment for Low Fecal Elastase Levels
Low fecal elastase levels can indicate potential pancreatic insufficiency, and the treatment typically involves pancreatic enzyme replacement therapy (PERT) 3, 4.
- The goal of PERT is to replace the missing pancreatic enzymes and improve nutrient absorption.
- Starting doses of PERT should be at least 30-40,000 IU with each meal and 15-20,000 IU with snacks 4.
- PERT should be taken in divided doses throughout meals to maximize its effectiveness.
Diagnosis and Testing
Before starting PERT, it's essential to confirm the diagnosis of pancreatic insufficiency through testing, including fecal elastase-1 (FE-1) levels 3, 5, 6.
- A low FE-1 level can indicate pancreatic insufficiency, but it's crucial to consider the type of stool sample used for testing, as watery samples may lead to falsely low results 5.
- Repeat testing with a formed stool sample may be necessary to confirm the diagnosis.
Factors Influencing Treatment Response
The response to PERT can be influenced by various factors, including the severity of pancreatic insufficiency and the presence of abnormal pancreatic imaging 3.
- Patients with abnormal pancreatic imaging are more likely to respond to PERT, with an odds ratio of 10.70 (95% confidence interval 1.62-70.70; p=0.01) 3.
- Patients who do not respond to initial dosages of PERT should be evaluated for alternative etiologies, and their PERT regimen should be optimized 4.