Can pancreatic enzyme replacement therapy (PERT) help manage pancreatic-associated diarrhea?

Pancreatic Enzyme Replacement Therapy for Pancreatic-Associated Diarrhea

Pancreatic enzyme replacement therapy (PERT) is highly effective for managing pancreatic-associated diarrhea and should be initiated promptly when exocrine pancreatic insufficiency (EPI) is diagnosed through clinical signs, symptoms, or laboratory tests of malabsorption. 1

Diagnosis of Pancreatic-Associated Diarrhea

• EPI is characterized by inadequate secretion of pancreatic enzymes leading to maldigestion and malabsorption, commonly presenting as steatorrhea, diarrhea, weight loss, and nutritional deficiencies 1
• Fecal elastase test is the most appropriate initial diagnostic test (performed on solid stool specimen); levels <100 μg/g provide good evidence of EPI 1
• Clinical symptoms suggesting EPI include steatorrhea, unexplained weight loss, bloating, excessive flatulence, and deficiencies of fat-soluble vitamins 1, 2

Treatment with PERT

Dosing and Administration

• Initial treatment should be at least 40,000 USP units of lipase with each meal and half that amount (20,000 USP units) with snacks in adults 1
• PERT must be taken during meals, not before or after, to maximize mixing and digestion of nutrients 1
• Dosage should be adjusted based on meal size and fat content 1

Available Formulations

• All FDA-approved PERT products are derived from porcine sources and are equally effective at equivalent doses 1
• Enteric-coated preparations are preferred as they prevent enzyme inactivation by gastric acid 1
• Available FDA-approved formulations include:
  • Creon (enteric-coated microspheres): 3,000-36,000 USP lipase units 1
  • Zenpep (enteric-coated beads): 3,000-40,000 USP lipase units 1
  • Pancreaze (enteric-coated microtablets): 2,600-37,000 USP lipase units 1
  • Pertzye (enteric-coated microspheres): 4,000-24,000 USP lipase units 1
  • Viokace (non-enteric-coated tablets): 10,444-20,880 USP lipase units (requires acid-reducing agent) 1

Important Considerations

• Over-the-counter pancreatic enzyme supplements should NOT be used as they are unregulated dietary supplements with unknown efficacy and safety 1
• Non-enteric-coated preparations require co-treatment with acid-reducing agents (H2 blockers or proton pump inhibitors) 1
• Acid-reducing agents may also improve efficacy of enteric-coated preparations in some patients 1

Monitoring Treatment Response

• Successful treatment is indicated by 1:
  • Reduction in steatorrhea and associated gastrointestinal symptoms
  • Weight gain and improved muscle mass/function
  • Improvement in fat-soluble vitamin levels
• Regular monitoring should include 1:
  • Nutritional status assessment (BMI, muscle mass, fat-soluble vitamins)
  • Evaluation of gastrointestinal symptoms
  • Assessment of dietary intake and PERT compliance
• Stable patients should have pancreatic disease status assessed at least annually 1

Dietary Considerations

• Low-moderate fat diet with frequent smaller meals is recommended 1
• Very low-fat diets should be avoided 1
• Routine supplementation and monitoring of fat-soluble vitamins (A, D, E, K) is appropriate 1

Clinical Pitfalls to Avoid

• Delaying initiation of PERT when EPI is diagnosed can lead to malnutrition, decreased quality of life, and increased mortality 1
• Administering enzymes before or after meals rather than during meals reduces efficacy 1
• Using inadequate dosage of enzymes may result in continued maldigestion symptoms 1, 2
• Failing to monitor treatment response and adjust dosage accordingly 1, 3
• Neglecting to assess for and treat fat-soluble vitamin deficiencies 1

PERT is a crucial intervention for patients with pancreatic-associated diarrhea due to EPI, with demonstrated efficacy in reducing diarrhea duration, improving nutritional status, and enhancing quality of life 4, 5.