From the Guidelines
The management of chronic pancreatitis should prioritize a multifaceted approach, focusing on pain control, addressing pancreatic insufficiency, and managing complications, as outlined in the most recent guidelines 1.
Key Components of Management
- Pain management: begins with acetaminophen and NSAIDs, progressing to weak opioids like tramadol, and then stronger opioids such as morphine or oxycodone for severe pain, with adjuvant medications including pregabalin, gabapentin, or tricyclic antidepressants like amitriptyline to manage neuropathic pain components.
- Pancreatic exocrine insufficiency: pancreatic enzyme replacement therapy (PERT) is essential, with typical dosing adjusted based on symptom response, and proton pump inhibitors like omeprazole or pantoprazole can improve enzyme efficacy.
- Nutritional support: small, frequent, low-fat meals and abstinence from alcohol and tobacco, with fat-soluble vitamin supplementation (A, D, E, K) as necessary.
- Diabetes management: often requires insulin therapy due to beta-cell destruction.
- Endoscopic interventions: like stenting or surgical procedures may be considered for ductal strictures, pseudocysts, or intractable pain.
Nutritional Considerations
- Patients with chronic pancreatitis are at risk of malnutrition and should be screened and supplemented accordingly 1.
- Osteoporosis and increased fracture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered 1.
- The diet should be rich in carbohydrates and protein, although carbohydrate intake can cause problems with intercurrent diabetes, and a protein intake of 1.0–1.5 g/kg is sufficient and well tolerated 1.
Enzyme Replacement and Supplementation
- An adequate intake of enzyme products is crucial, and in cases of therapeutic resistance, H2-antagonists or proton-pump-inhibitors can be added 1.
- Fat-soluble vitamins (vitamin A, D, E, K) as well as other micronutrients should be supplemented if clinical deficit is apparent 1.
Enteral Nutrition
- EN is indicated if patients cannot ingest sufficient calories, and it is recommended that EN be delivered via a jejunal tube, with a peptide or amino acid-based formula given overnight 1.
Parenteral Nutrition
- PN is only indicated when EN is not possible, such as in severe stenosis of the duodenum prior to surgery 1.
This approach, based on the most recent and highest quality evidence 1, prioritizes the management of symptoms, prevention of malnutrition, and slowing of disease progression, ultimately aiming to improve morbidity, mortality, and quality of life for patients with chronic pancreatitis.
From the FDA Drug Label
The final analysis population was limited to 52 patients; 2 patients were excluded due to protocol violations. Ten patients had a history of pancreatectomy (7 were treated with CREON) In this study, patients received placebo for 5 days (run-in period), followed by pancreatic enzyme replacement therapy as directed by the investigator for 16 days; this was followed by randomization to CREON or matching placebo for 7 days of treatment (double-blind period). Only patients with CFA less than 80% in the run-in period were randomized to the double-blind period All patients were to consume a high-fat diet (greater than or equal to 100 grams of fat/day) during the treatment period. The dosage of CREON during the double-blind period was 72,000 lipase units per main meal (3 main meals) and 36,000 lipase units per snack (2 snacks) [approximately 1,000 lipase units/kg/meal]
The management approach for chronic pancreatitis involves the use of pancreatic enzyme replacement therapy, such as CREON, to improve fat absorption and manage symptoms. The recommended dosage is 72,000 lipase units per main meal and 36,000 lipase units per snack, with patients consuming a high-fat diet during treatment. Key points to consider:
- Pancreatic enzyme replacement therapy is the primary management approach for chronic pancreatitis.
- CREON is a specific pancreatic enzyme replacement therapy that has been shown to improve fat absorption in patients with chronic pancreatitis.
- Patients should consume a high-fat diet during treatment to maximize the effectiveness of CREON.
- The recommended dosage of CREON is 72,000 lipase units per main meal and 36,000 lipase units per snack 2.
From the Research
Management Approach for Chronic Pancreatitis
The management of chronic pancreatitis involves a multi-faceted approach, with pain control being a central aspect of treatment.
- Pain management is crucial in chronic pancreatitis, as patients often experience severe and unrelenting abdominal pain that significantly impacts their quality of life 3.
- Various strategies are employed to manage pain in chronic pancreatitis, including the use of opioid medications, with a focus on safe prescription monitoring practices 3.
- The use of pregabalin has been shown to be effective in reducing pain in chronic pancreatitis patients, with responders exhibiting increased endogenous inhibitory modulation 4.
Pharmacological Management
Pharmacological management of pain in chronic pancreatitis includes the use of oral analgesics and enzyme preparations.
- A summary of the evidence base for different pharmacological treatments in chronic pancreatitis has shown that large-scale trials evaluating their efficacy in managing pain are lacking 5.
- The use of 'alternative' treatments such as antioxidant preparations and enzyme antagonists has shown promise in managing pain in chronic pancreatitis 5.
- Opioids, such as tramadol and oxycodone, may be effective in managing pain in chronic pancreatitis, with tramadol being as effective as morphine but with fewer side effects 5.
- Paracetamol is also used to treat mild or moderate pain in chronic pancreatitis, but patients with the condition may have lower concentrations of the drug, potentially requiring additional analgesic therapy 6.
Treatment Considerations
When managing chronic pancreatitis, it is essential to consider the individual patient's needs and response to treatment.