From the Guidelines
Pancreatic insufficiency should be treated with pancreatic enzyme replacement therapy (PERT) to improve outcomes and quality of life, with a typical starting dose of at least 40,000 USP units of lipase during each meal in adults and one-half of that with snacks, as recommended by the AGA clinical practice update 1.
Diagnosis and Treatment
The diagnosis of pancreatic insufficiency can be made using the fecal elastase test, which is the most appropriate initial test, and should be performed on a semi-solid or solid stool specimen 1. A fecal elastase level <100 mg/g of stool provides good evidence of EPI, and levels of 100–200 mg/g are indeterminate for EPI.
PERT Formulations and Dosage
PERT formulations are all derived from porcine sources and are equally effective at equivalent doses, 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 the subsequent dosage can be adjusted based on the meal size and fat content 1.
Dietary Management and Monitoring
Dietary modifications include a low-moderate fat diet with frequent smaller meals and avoiding very-low-fat diets, and routine supplementation and monitoring of fat-soluble vitamin levels are appropriate 1. Patients should monitor for symptoms like steatorrhea, weight loss, and abdominal discomfort to gauge treatment effectiveness.
Key Points
- PERT should be taken during the meal to maximize mixing and digestion of nutrients 1.
- The primary goal of PERT is to ensure adequate digestion of lipids to meet macro-nutritional needs, with a secondary goal to reduce steatorrhea and intestinal symptoms that may be diet-related 1.
- Measures of successful treatment with PERT include reduction in steatorrhea and associated gastrointestinal symptoms; a gain of weight, muscle mass, and muscle function; and improvement in fat-soluble vitamin levels 1.
From the Research
Causes and Symptoms of Pancreatic Insufficiency
- Pancreatic insufficiency can be caused by various conditions, including chronic pancreatitis, cystic fibrosis, and pancreatic cancer 2.
- Symptoms of pancreatic insufficiency include steatorrhea, malabsorption of nutrients, and weight loss 3, 4.
- The lack of pancreatic enzymes leads to inadequate absorption of fat, proteins, and carbohydrates, causing abdominal discomfort and nutritional deficiencies 4.
Diagnosis of Pancreatic Insufficiency
- Testing fecal elastase-1 level is useful for the diagnosis of pancreatic exocrine insufficiency 2.
- Diagnosis of pancreatic insufficiency is crucial to commence pancreatic enzyme replacement therapy (PERT) as soon as possible to avoid malnutrition-related morbidity and mortality 4.
Treatment of Pancreatic Insufficiency
- Pancreatic enzyme replacement therapy (PERT) is the standard treatment for exocrine pancreatic insufficiency (EPI) 5.
- Starting doses of PERT should be at least 30-40,000 IU with each meal and 15-20,000 IU with snacks 2.
- PERT should be taken in divided doses throughout meals, and patients who do not respond to initial dosages should be evaluated for alternative etiologies and PERT optimized 2.
- The most common dosing guidelines focus on starting doses at 40,000-50,000 units of lipase/meal with increases of up to two to three times this amount before pursuing additive therapies 5.
Challenges and Future Developments
- Despite the efficacy of PERT, challenges still remain, including enzyme destruction in the stomach, lack of adequate mixing with the chyme in the duodenum, and failing to deliver and activate at the appropriate time 6.
- Current research is aimed at studying new enzymes and delivery systems to improve the efficiency of action in the duodenum along with developing better means to monitor therapy 6.
- Healthcare providers should consider individualizing PERT dosing based on nutritional status and response to therapy, ensuring regular follow-up with patients for dose titrations 5.