Indications for Starting PERT
Initiate PERT immediately without testing in patients post-total pancreatectomy, and start PERT when fecal elastase is <100 μg/g or when clinical signs of malabsorption (steatorrhea, weight loss, malnutrition) are present in high-risk conditions including severe chronic pancreatitis, cystic fibrosis, and pancreatic head malignancy. 1
Clinical Scenarios Requiring Immediate PERT Initiation (No Testing Needed)
Total pancreatectomy patients require immediate PERT without any pancreatic function testing, as this definitively causes exocrine pancreatic insufficiency. 1, 2
High-Risk Conditions Where PERT Should Be Started After Diagnostic Confirmation
Definite/Expected EPI (Start PERT with positive testing):
Possible EPI (Consider testing and treatment):
- Mild to moderate chronic pancreatitis 1
- Severe acute pancreatitis 1
- Pancreatic malignancy of body/tail 1
- Bariatric GI surgery 1
Clinical and Laboratory Criteria for Starting PERT
Clinical Signs (Start PERT when present):
PERT should be initiated when clinical signs of malabsorption or anthropometric/biochemical signs of malnutrition are present, even without formal steatorrhea quantification. 1
Classic symptoms:
Under-recognized symptoms that warrant evaluation:
Nutritional markers indicating need for PERT:
- Low albumin, cholinesterase, prealbumin, retinol-binding protein, or magnesium 1
- Altered body composition on bioimpedance analysis 1
- Deficiencies of fat-soluble vitamins (A, D, E, K) even in mild to moderate PEI 1
Laboratory Testing Thresholds:
Fecal elastase <100 μg/g provides good evidence of EPI and is an indication to start PERT. 1 Levels of 100-200 μg/g are indeterminate. 1
Alternative diagnostic criteria include:
Critical Pitfalls to Avoid
Do not delay PERT initiation in total pancreatectomy patients waiting for diagnostic testing—this definitively causes EPI. 2
Do not overlook patients with under-recognized symptoms (diarrhea, bloating, flatulence without overt steatorrhea), as these may represent significant EPI requiring treatment. 1
Absence of overt steatorrhea does not indicate adequate absorption—biochemical malnutrition and vitamin deficiencies can occur even without obvious steatorrhea. 1
Untreated EPI leads to serious complications including osteoporosis, sarcopenia, reduced quality of life, higher surgical complication rates, and increased mortality. 1
Poor awareness of EPI among primary care physicians leads to delayed diagnosis and inappropriate dietary restrictions that worsen outcomes. 1
Initial Dosing When Starting PERT
The typical starting dose is 500 units of lipase per kg per meal (e.g., 40,000 U for an 80 kg patient) and 250 units of lipase per kg per snack (20,000 U for an 80 kg patient). 1, 2
Titrate upward as needed to control steatorrhea and GI symptoms, with a maximum dose of 2,500 units of lipase per kg per meal or 10,000 units of lipase per kg per day. 1, 2
Use enteric-coated, pH-sensitive microsphere formulations (Creon, Zenpep, Pancreaze, Pertzye) as they are superior to conventional preparations. 1, 2
Concurrent Management When Starting PERT
Implement dietary management with high-protein foods and avoid very low-fat diets. 1, 4
Supplement with fat-soluble vitamins (A, D, E, K) to prevent deficiencies. 1, 4
Avoid alcohol and tobacco. 1
Plan for annual assessment of micronutrient status (fat-soluble vitamins, B12, folate, thiamine, selenium, zinc, magnesium) and endocrine function (glucose, HbA1c). 1, 2
Obtain baseline and repeat DEXA scans every 1-2 years due to high osteoporosis risk. 1, 2