What vitamin deficiencies are associated with chronic pancreatitis?

From the Guidelines

Chronic pancreatitis is commonly associated with deficiencies in fat-soluble vitamins, including vitamins A, D, E, and K, as well as several B vitamins, particularly B12, due to pancreatic enzyme insufficiency impairing fat digestion and absorption of fat-soluble nutrients. The prevalence of biochemical vitamin deficiency in chronic pancreatitis differs widely between studies and between countries, with vitamin A deficiency reportedly as low as 3% and as high as 40%, and vitamin E deficiency prevalence varying from 25% to about 75% of patients with chronic pancreatitis 1.

Vitamin Deficiencies and Supplementation

To address these deficiencies, patients should take pancreatic enzyme replacement therapy (PERT) with meals, typically starting at 25,000-40,000 units of lipase per meal, to improve nutrient absorption 1. Supplementation should include a daily multivitamin plus specific supplements, with vitamin D supplementation being effective in increasing serum 25OHD levels, either through oral supplementation of 38 μg (1520 IU)/d or a once-off, high-dose intramuscular injection of 15,000 μg (600,000 IU) 1.

Monitoring and Adjustment

Regular monitoring of vitamin levels every 6-12 months is essential, with dose adjustments as needed. The use of PERT in patients with chronic pancreatitis and exocrine pancreatic insufficiency improves outcomes, and failure to properly provide PERT in adequate doses results in a continuation of maldigestion symptoms, micro- or macro-nutritional deficiencies, poor quality of life, and increased mortality 1. Zinc deficiency is also common and may require supplementation (25-50 mg daily). These deficiencies contribute to complications like osteoporosis, neuropathy, and increased bleeding risk, making supplementation crucial for preventing long-term complications of chronic pancreatitis.

Best Practice Advice

Best practice advice includes taking PERT during the meal, with the initial treatment of at least 40,000 USP units of lipase during each meal in adults and one-half of that with snacks, and adjusting the subsequent dosage based on the meal size and fat content 1. Over-the-counter commercially available pancreas enzyme replacements should not be used, as they are classified as dietary supplements only, and their dosing and efficacy are neither standardized nor regulated 1.

From the Research

Vitamin Deficiencies in Chronic Pancreatitis

• Fat-soluble vitamin deficiencies are common in patients with chronic pancreatitis, including vitamins A, D, E, and K 2, 3, 4, 5, 6
• The prevalence of vitamin deficiencies in chronic pancreatitis patients varies, with reported rates of:
  • Vitamin A deficiency: 3-16.8% 2, 4, 5
  • Vitamin D deficiency: 53-57.6% 2, 5
  • Vitamin E deficiency: 10-29.2% 2, 4, 5
  • Vitamin K deficiency: 63% 2
• Exocrine pancreatic insufficiency (EPI) may increase the risk of fat-soluble vitamin deficiencies, but the relationship is not entirely clear 3, 5
• Routine screening for fat-soluble vitamin deficiencies and decreased bone mineral density is recommended for all patients with chronic pancreatitis, regardless of EPI status 2, 3

Factors Contributing to Vitamin Deficiencies

• Malabsorption of fat due to loss of exocrine function is a major contributor to fat-soluble vitamin deficiencies in chronic pancreatitis patients 2, 6
• Pancreatic enzyme replacement therapy may help improve fat absorption and reduce the risk of vitamin deficiencies, but more research is needed to determine its effectiveness 3
• Dietary intake of fat-soluble vitamins should be evaluated and supplemented as necessary to prevent deficiencies 6