From the Guidelines
The treatment of elevated lipase focuses on addressing the underlying cause rather than treating the enzyme elevation itself, with the most recent and highest quality study 1 suggesting that the typical starting dose for pancreatic enzyme replacement therapy (PERT) is 500 units of lipase per kg per meal. For acute pancreatitis, which is the most common cause of high lipase, treatment includes:
- Bowel rest with nothing by mouth (NPO)
- Aggressive intravenous fluid resuscitation with lactated Ringer's solution at 5-10 mL/kg/hr initially
- Adequate pain control with opioid analgesics like morphine or hydromorphone Nutritional support should be initiated within 24-48 hours, preferably via enteral feeding if tolerated. For gallstone pancreatitis, early ERCP (within 24-48 hours) is recommended if there is evidence of biliary obstruction or cholangitis. Alcohol-induced pancreatitis requires alcohol cessation and thiamine supplementation (100 mg daily). Hypertriglyceridemia-related elevations should be managed with fibrates (like fenofibrate 145 mg daily), statins, or omega-3 fatty acids, along with dietary fat restriction, as suggested by 1 and 1. For medication-induced lipase elevation, the offending drug should be discontinued when possible. Chronic pancreatitis may require PERT such as pancrelipase 25,000-40,000 units with meals, with the goal of reducing steatorrhea and associated gastrointestinal symptoms, as well as improving fat-soluble vitamin levels, as recommended by 1 and 1. Lipase elevation is significant because it reflects pancreatic inflammation or injury, and persistent elevation can indicate ongoing damage that may lead to pancreatic insufficiency if left untreated. 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, as suggested by 1. Monitoring nutritional status is essential in those with exocrine pancreatic insufficiency (EPI), with baseline measurements of nutritional status, including body mass index, quality-of-life measure, and fat-soluble vitamin levels, as recommended by 1. In those with chronic pancreatitis (CP), obtaining baseline measurements of symptoms and quality of life can also be useful in assessing the effectiveness of therapy, with annual updates of measurements of fat-soluble vitamins and serum markers of malnutrition, as suggested by 1.
From the Research
Treatment for Hyperlipasemia
The treatment for hyperlipasemia, or elevated lipase levels, depends on the underlying cause of the condition.
- In cases where hyperlipasemia is caused by acute pancreatitis, treatment may involve supportive care, such as pain management, volume substitution, and treatment of pulmonary and renal failure 2.
- For patients with biliary pancreatitis, extraction of biliary stones after papillotomy may be indicated, and in severe cases, this procedure should be done without delay 2.
- Enteral nutrition is also a standard treatment for acute pancreatitis, although the data supporting its use are not completely convincing 2.
- In cases where hyperlipasemia is caused by other conditions, such as acute gastroenteritis or Crohn's disease, treatment may involve antibiotics or other supportive measures 3.
- For patients with non-gastrointestinal causes of hyperlipasemia, such as lupus nephritis or organophosphate poisoning, treatment may involve supportive care and management of the underlying condition 3.
Diagnostic Approach
It is essential to take a systematic approach to diagnosing the cause of hyperlipasemia, as the differential diagnosis is broad and includes various conditions such as acute pancreatitis, chronic pancreatitis, gastrointestinal tract obstruction, malignancies, and other disease conditions 4.
- A diagnosis of acute pancreatitis should be confirmed by the presence of characteristic abdominal pain or cross-sectional imaging, in addition to elevated lipase levels 5.
- The optimal diagnostic lipase cutoff for acute pancreatitis in critically ill patients is 532 IU/L, which correlates with a sensitivity, specificity, negative predictive value, and positive predictive value of 77.4%, 78.0%, 84.9%, and 67.0%, respectively 5.