What is the relationship between the pancreas and malabsorption?

From the Guidelines

Pancreatic enzyme replacement therapy (PERT) is the primary treatment for malabsorption due to pancreatic insufficiency, and it should be taken during meals with an initial dose of at least 40,000 USP units of lipase in adults. The pancreas plays a crucial role in digestion, and when it malfunctions, malabsorption can occur. Malabsorption happens when the pancreas fails to produce sufficient digestive enzymes (pancreatic exocrine insufficiency), preventing proper breakdown and absorption of nutrients.

Key Considerations

• The use of PERT in patients with chronic pancreatitis (CP) and exocrine pancreatic insufficiency (EPI) improves outcomes, as noted in the AGA Clinical Practice Update on Exocrine Pancreatic Insufficiency 1.
• PERT is also essential in managing EPI and nutrition in patients with cystic fibrosis 1.
• In patients with pancreatic cancer, EPI is associated with reduced quality of life and survival, and the use of PERT appears to improve outcomes after pancreatoduodenectomy 1.

Treatment Approach

• PERT should be taken during meals, 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 1.
• The subsequent dosage can be adjusted based on the meal size and fat content.
• Acid-reducing agents may be required for non–enteric-coated preparations, but not for enteric-coated preparations 1.
• Routine supplementation monitoring of fat-soluble vitamin levels is appropriate, and dietary modifications include a low-moderate fat diet with frequent smaller meals and avoiding very-low-fat diets 1.

Important Considerations

• 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.
• The efficacy of PERT should be evaluated by the relief of gastrointestinal symptoms and the improvement of nutritional parameters (anthropometric and biochemical) 1.

From the FDA Drug Label

CREON is a prescription medicine used to treat people who cannot digest food normally because their pancreas does not make enough enzymes. CREON contains a mixture of digestive enzymes including lipases, proteases, and amylases from pig pancreas. CREON is safe and effective in adults and children

The pancrelipase (PO) is used to treat people with exocrine pancreatic insufficiency, which can lead to malabsorption of nutrients.

• The medication works by replacing the missing enzymes in the pancreas, allowing for proper digestion and absorption of nutrients.
• Malabsorption can occur when the pancreas does not produce enough enzymes, leading to symptoms such as abdominal pain, bloating, and weight loss.
• The CREON medication has been shown to be effective in improving coefficient of fat absorption (CFA) and coefficient of nitrogen absorption (CNA) in patients with exocrine pancreatic insufficiency 2.

From the Research

Pancreas and Malabsorption

• Malabsorption due to severe pancreatic exocrine insufficiency is a significant feature of chronic pancreatitis, with steatorrhea being more severe and occurring several years prior to malabsorption of other nutrients 3.
• The lack of pancreatic enzymes leads to inadequate absorption of fat, proteins, and carbohydrates, causing steatorrhea, abdominal discomfort, weight loss, and nutritional deficiencies 4.
• Pancreatic enzyme replacement therapy is currently the mainstay of treatment for nutrient malabsorption secondary to pancreatic insufficiency, and is safe with few side effects 5.

Treatment of Malabsorption

• Adequate nutrient absorption requires delivery of sufficient enzymatic activity into the duodenal lumen simultaneously with meal nutrients, with recommended doses of 25,000 to 40,000 units of lipase per meal 3.
• Treatment failure is addressed in a sequential fashion, with current research aimed at studying new enzymes and delivery systems to improve efficiency of action in the duodenum 5.
• Starting doses of pancreatic enzyme replacement therapy should be at least 30-40,000 IU with each meal and 15-20,000 IU with snacks, and should be taken in divided doses throughout meals 6.

Options for Addressing Exocrine Pancreatic Insufficiency

• Enteral nutrition support is used to augment nutritional status in patients with exocrine pancreatic insufficiency, with semielemental enteral nutrition formulas being advantageous as they contain hydrolyzed protein, shorter chain carbohydrates, and may contain medium chain triglycerides as a fat source 7.
• RELiZORB, a novel in-line digestive cartridge, has been designed to address the unmet need for pancreatic enzyme replacement therapy in patients receiving enteral nutrition, and has been shown to efficiently hydrolyze greater than 90% of fats within the formula into absorbable fatty acids and monoglycerides 7.