From the Guidelines
Managing chronic pancreatitis requires a comprehensive approach focusing on pain control, nutritional support, and addressing complications, with surgical intervention being considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis, as recommended by the most recent guidelines 1.
Key Components of Management
- Lifestyle modifications: complete alcohol cessation and smoking cessation to prevent disease progression
- Pain management: starts with acetaminophen, may progress to NSAIDs, then weak opioids like tramadol, and finally stronger opioids like morphine or hydrocodone for severe pain, with adjuvant medications such as pregabalin (150-300 mg daily) or gabapentin (300-1200 mg daily) for neuropathic pain
- Pancreatic enzyme replacement therapy (PERT): essential, with typical dosing of 25,000-40,000 units of lipase with meals and 10,000-25,000 units with snacks, adjusted based on response, as supported by earlier studies 1
- Nutritional support: low-fat diet (less than 30% of calories from fat), frequent small meals, and supplementation with fat-soluble vitamins (A, D, E, K), with consideration of medium chain triglycerides (MCT) for persistent steatorrhoea, as discussed in the context of nutritional management 1
Addressing Complications
- Endoscopic interventions: may be necessary for complications like strictures or pseudocysts
- Surgery: reserved for cases with ductal obstruction, suspected malignancy, or intractable pain, with surgical intervention being the preferred approach for long-term treatment of patients with painful obstructive chronic pancreatitis, as per the latest expert review 1
- Regular monitoring of blood glucose: important as diabetes frequently develops, requiring appropriate management with oral hypoglycemics or insulin
Prioritizing Quality of Life
- A multifaceted approach: addresses the underlying inflammation, manages symptoms, and prevents complications, improving quality of life for patients with this chronic condition
- Consideration of the patient's overall health: including nutritional status, presence of diabetes, and other comorbidities, to provide personalized care and optimize outcomes, as emphasized in the discussion of nutrition in chronic pancreatitis 1
From the FDA Drug Label
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 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 Table 3: Change in Coefficient of Fat Absorption in Adults with Exocrine Pancreatic Insufficiency Due to Chronic Pancreatitis and Pancreatectomy (Study 4) CREON N = 24Placebo N = 28 CFA [%] Run-in Period (Mean, SD) 54 (19) 57 (21) End of Double-Blind Period (Mean, SD) 86 (6) 66 (20) Change in CFA * [%] Run-in Period to End of Double-Blind Period (Mean, SD) 32 (18) 9 (13) Treatment Difference (95% CI) 21 (14,28)
The management of chronic pancreatitis with exocrine pancreatic insufficiency may involve pancreatic enzyme replacement therapy, such as CREON, at a dosage of 72,000 lipase units per main meal and 36,000 lipase units per snack 2.
From the Research
Management of Chronic Pancreatitis
The management of chronic pancreatitis involves a combination of medical, endoscopic, and surgical modalities to alleviate symptoms and prevent complications.
- Medical management includes pharmacological approaches to manage pancreatic pain, such as central analgesics, enzyme supplements, and antioxidants 3.
- The first line of therapy consists of advice to discontinue use of alcohol and smoking, and taking analgesic agents (nonsteroidal anti-inflammatory drugs and weak opioids such as tramadol) 4.
- A trial of pancreatic enzymes and antioxidants (a combination of multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients 4.
- Patients with pancreatic ductal obstruction due to stones, stricture, or both may benefit from ductal drainage via endoscopic retrograde cholangiopancreatography (ERCP) or surgical drainage procedures 4.
Multidisciplinary Collaboration
Multidisciplinary collaboration (MDC) has been shown to improve the clinical outcome of patients with acute/chronic pancreatitis 5.
- MDC brings several specialized healthcare providers together to reach the goal of achieving the best diagnosis and treatment plan for complex diseases.
- The key members of pancreatitis MDM include gastroenterologists, radiologists, pathologists, hepatobiliary surgeons, chairperson, and a coordinator.
Pain Management
Pain control remains central to the overall management of chronic pancreatitis 6.
- Most of the strategies aimed at treating the pain of chronic pancreatitis are based on expert opinion and vary from one institution to another.
- Safe and efficacious prescription monitoring practices are essential when using opioid medications in patients with chronic pancreatitis 6.
Treatment Strategies
Treatment strategies for chronic pancreatitis include:
- Dietary restrictions
- Enzyme replacement
- Vitamin supplementation
- Surgical or endoscopic methods, depending on the role of the pancreatic ducts in the manifestation of disease 7.