Can I discontinue Creon (pancreatic enzyme replacement) in an outpatient with a history of pancreatic insufficiency or cystic fibrosis who is unsure of their treatment plan and the original rationale for starting the medication?

Discontinuing Creon in an Outpatient with Unknown Indication

Do not discontinue Creon without first establishing the original indication for pancreatic enzyme replacement therapy (PERT), as stopping it in patients with true exocrine pancreatic insufficiency (EPI) will lead to malnutrition, steatorrhea, and weight loss. 1

Immediate Steps to Determine if Discontinuation is Appropriate

Review the Patient's Medical History for EPI-Causing Conditions

You must identify whether your patient has any of the following conditions that cause EPI and require lifelong PERT 1:

• Cystic fibrosis (85% of CF patients have pancreatic insufficiency requiring lifelong PERT) 2
• Chronic pancreatitis (progressive condition with permanent loss of pancreatic function) 1, 3
• Pancreatic surgery (post-pancreatectomy or Whipple procedure) 1, 4
• Pancreatic cancer (often causes ductal obstruction) 1

If No Clear Indication is Found

If chart review reveals no documented EPI-causing condition, proceed with the following assessment 1:

• Check for symptoms of EPI: steatorrhea (oily, floating stools), chronic diarrhea, unintentional weight loss, abdominal bloating, flatulence 1, 3
• Review nutritional markers: body mass index, fat-soluble vitamin levels (A, D, E, K), albumin 1
• Consider objective testing if uncertain: 72-hour fecal fat collection (coefficient of fat absorption <80% confirms EPI) or fecal elastase-1 test 1, 5

When Discontinuation is Appropriate

You can safely discontinue Creon if the patient has no documented EPI-causing condition AND no symptoms of malabsorption AND normal nutritional status. 1 This scenario suggests the medication was started inappropriately or for a self-limited condition that has resolved.

Common Scenarios Where PERT May Have Been Inappropriately Started

• Acute pancreatitis (temporary condition that typically resolves without chronic EPI) 1
• Nonspecific gastrointestinal symptoms without confirmed EPI 1
• Empiric trial that was never reassessed 1

When Discontinuation is NOT Appropriate

Never discontinue PERT in patients with confirmed cystic fibrosis, chronic pancreatitis, or post-pancreatic surgery, as these conditions cause permanent pancreatic insufficiency requiring lifelong treatment. 1, 2, 4

Critical Monitoring if You Proceed with Discontinuation

If you decide to attempt discontinuation in a patient without clear indication 1:

• Monitor for return of symptoms: steatorrhea, weight loss, abdominal pain, increased stool frequency 1, 3
• Schedule follow-up within 4-8 weeks to assess nutritional status and symptoms 1
• Check fat-soluble vitamin levels at 3-6 months if discontinued 1
• Reinitiate PERT immediately if malabsorption symptoms develop 1

Dosing Considerations if Continuing PERT

If your investigation reveals a legitimate indication for PERT, ensure proper dosing 1:

• Standard adult dosing: minimum 40,000 USP units of lipase with each meal, half that amount with snacks 1
• Take during the meal (not before or after) to maximize mixing with food 1
• Adjust based on meal size and fat content, not on a fixed schedule 1

Common Pitfall to Avoid

The most dangerous error is discontinuing PERT in a patient with true EPI based solely on the patient's lack of knowledge about why they're taking it. 1 Many patients with CF or chronic pancreatitis may not fully understand their diagnosis but absolutely require lifelong enzyme replacement. Always verify the underlying diagnosis through chart review, specialist consultation, or objective testing before discontinuation. 1, 2