What supplements, dietary supplements, and medications can be used to manage pancreatitis?

Management of Pancreatitis: Supplements, Dietary Supplements, and Medications

Acute Pancreatitis

No specific pharmacological treatment should be given for acute pancreatitis except for organ support and nutrition. 1

Antibiotics in Acute Pancreatitis

• Routine prophylactic antibiotics are NOT recommended for patients with acute pancreatitis, as they are not associated with decreased mortality or morbidity 1
• Antibiotics should only be administered to treat documented infected acute pancreatitis, not as prophylaxis 1

For infected severe acute pancreatitis in immunocompetent patients without MDR colonization: 1

• Meropenem 1 g q6h by extended infusion or continuous infusion
• Doripenem 500 mg q8h by extended infusion or continuous infusion
• Imipenem/cilastatin 500 mg q6h by extended infusion or continuous infusion

For patients with suspected MDR etiology: 1

• Imipenem/cilastatin-relebactam 1.25 g q6h by extended infusion, OR
• Meropenem/vaborbactam 2 g/2 g q8h by extended infusion or continuous infusion, OR
• Ceftazidime/avibactam 2.5 g q8h by extended infusion or continuous infusion + Metronidazole 500 mg q8h

For patients with documented beta-lactam allergy: 1

• Eravacycline 1 mg/kg q12h

Nutrition in Acute Pancreatitis

Severity-based nutritional approach: 1

• Mild acute pancreatitis: General (regular) diet and advance as tolerated 1
• Moderately severe acute pancreatitis: Enteral nutrition (oral, NG or NJ); if not tolerated, parenteral nutrition may be used 1
• Severe acute pancreatitis: Enteral nutrition (oral, NG or NJ); if not tolerated, parenteral nutrition may be used 1

Key nutritional principles: 1

• Oral refeeding with a diet rich in carbohydrates and proteins and low in fats is recommended
• Avoid overfeeding: patients should receive 25 non-protein kcal/kg per day, increasing to no more than 30 kcal/kg per day maximum 1
• Reduce to 15-20 non-protein kcal/kg per day in cases with SIRS or MODS and when at risk of refeeding syndrome 1

Medications NOT Recommended in Acute Pancreatitis

The following have no proven value and cannot be recommended: 1

• Aprotinin
• Glucagon
• Somatostatin
• Fresh frozen plasma
• Peritoneal lavage

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Chronic Pancreatitis

Pancreatic Enzyme Replacement Therapy (PERT)

Pancreatic enzymes supplemented with meals are the mainstay of treatment for chronic pancreatitis with exocrine insufficiency. 1, 2

PERT formulation and dosing: 2, 3

• Use pH-sensitive, enteric-coated microspheres that protect enzymes from gastric acidity and allow disintegration at pH >5.5 in the duodenum 2
• Mini-microspheres 1.0-1.2 mm in diameter have higher therapeutic efficacy compared to larger microspheres 2
• Dosage: 4,000 lipase units/g fat ingested/day 3
• Do not exceed 2,500 lipase units/kg/meal, 10,000 lipase units/kg/day, or 4,000 lipase units/g fat ingested/day in pediatric patients >12 months 3

Common pitfall: Do not crush or chew CREON capsules or mix contents in foods with pH >4.5, as this disrupts the protective enteric coating and results in early enzyme release, oral mucosa irritation, and loss of enzyme activity 3

If therapeutic resistance occurs despite adequate PERT: 1

• Add H2-antagonists or proton-pump inhibitors to reduce gastric acid and improve enzyme efficacy 1

Dietary Recommendations

More than 80% of patients can be treated adequately with normal food supplemented by pancreatic enzymes. 1

Specific dietary approach: 1, 2

• High protein diet: 1.0-1.5 g/kg body weight 1, 2
• High energy diet in five to six small meals per day 2
• 30% of calories can be given as fat, which is well tolerated, especially vegetable fat 1
• No dietary fat restriction is needed unless steatorrhea symptoms cannot be controlled 2
• Diet should be low in fiber, since fibers absorb enzymes and reduce nutrient intake 1

Medium Chain Triglycerides (MCT)

If adequate weight gain cannot be achieved and steatorrhea persists despite PERT: 1, 2

• Medium chain triglycerides (MCT) can be administered due to lipase-independent absorption 1, 2
• Caution: MCTs have lower energy density (8.3 kcal/g), are not very palatable, and may induce side effects such as abdominal pain, nausea, and diarrhea 1

Fat-Soluble Vitamin Supplementation

Fat-soluble vitamins (A, D, E, K) should be supplemented if clinical deficit is apparent. 1, 2

Vitamin D supplementation: 2

• Vitamin D deficiency is particularly common (58-78% of patients) 2
• Oral supplementation: 38 μg (1520 IU)/day 2
• Intramuscular injection: 15,000 μg (600,000 IU) as an effective alternative 2

Important caveat: Blind supplementation of all fat-soluble vitamins is not advised, as some patients may have excess levels (particularly vitamin A) 2

Water-Soluble Vitamins and Minerals

Monitor and supplement if deficiencies are detected: 2

• Thiamine (especially with concomitant alcoholism) 2
• Magnesium (may correlate with exocrine failure) 2
• Iron 2
• Selenium 2
• Zinc 2

Oral Nutritional Supplements (ONS)

10-15% of all patients require ONS. 1

If whole protein ONS are not well tolerated: 1

• Try peptide-based ONS, which are probably more efficient than whole-protein ONS 1
• Note: The palatability of peptide supplements is low and compliance is poor 1

Enteral Nutrition (Tube Feeding)

Tube feeding is indicated in approximately 5% of patients with chronic pancreatitis. 1

Indications for enteral nutrition: 1

• Patients cannot ingest sufficient calories due to pain
• Pyloro-duodenostenosis due to enlarged pancreatic head or pseudocyst formation
• Weight loss continues despite apparently adequate normal food
• Presence of acute complications (acute pancreatitis or fistulas)
• Prior to surgery

Delivery method: 1, 2

• EN should be delivered via a jejunal tube 1
• For long-term therapy (>30 days), use percutaneous endoscopic gastrostomy (PEG) with jejunal tube 1, 2
• Semi-elemental enteral formulas with MCTs are more suitable for jejunal nutrition compared to polymeric formulas 2
• A peptide or amino acid based formula is recommended, given overnight 1

Parenteral Nutrition

Parenteral nutrition is only indicated when enteral nutrition is not possible (e.g., severe stenosis of the duodenum prior to surgery). 1

Pain Management

Analgesics should be consumed before meals, since reduction in postprandial pain results in increased food intake and improved nutritional status. 1

Alcohol Abstinence

Standard therapeutic measures include abstinence from alcohol and pain control. 1