What is the management for chronic pancreatitis?

From the Guidelines

Chronic pancreatitis treatment should prioritize a comprehensive approach, focusing on managing pain, improving digestive function, and addressing complications, with the most recent and highest quality study suggesting that pancreatic enzyme replacement therapy (PERT) and lifestyle modifications are crucial. The management of chronic pancreatitis involves several key components, including:

• Pain management, which typically involves a step-up approach starting with acetaminophen or NSAIDs, then progressing to weak opioids like tramadol, and finally stronger opioids like morphine if needed, as suggested by 1
• Digestive problems, which can be addressed with PERT, such as Creon or Zenpep, taken with meals at doses of 25,000-40,000 lipase units per meal and 10,000-25,000 units with snacks, as recommended by 1
• Lifestyle modifications, including complete alcohol abstinence, smoking cessation, and following a low-fat diet (less than 30% of calories from fat), as emphasized by 1
• Nutritional support, which may be necessary, and fat-soluble vitamin supplements (A, D, E, K) are often recommended, as noted by 1
• Endoscopic procedures or surgery might be considered for complications like pseudocysts, bile duct strictures, or when pain remains uncontrolled, as suggested by 1
• Regular monitoring of blood glucose is important as diabetes frequently develops, as highlighted by 1 This comprehensive approach addresses both symptom management and the underlying inflammatory process that damages pancreatic tissue, with the goal of improving morbidity, mortality, and quality of life outcomes. Some key points to consider in the management of chronic pancreatitis include:
• The importance of early identification and treatment of steatorrhoea with PERT, as emphasized by 1
• The need for careful monitoring of blood glucose levels and management of diabetes, as noted by 1
• The potential benefits of antioxidant therapy, such as selenium, vitamin C, vitamin E, methionine, and beta-carotene, in reducing pain, as suggested by 1
• The importance of lifestyle modifications, including complete alcohol abstinence, smoking cessation, and following a low-fat diet, as emphasized by 1 Overall, the management of chronic pancreatitis requires a comprehensive and individualized approach, taking into account the patient's specific needs and circumstances, with the goal of improving morbidity, mortality, and quality of life outcomes, as suggested by the most recent and highest quality study 1.

From the FDA Drug Label

The final analysis population was limited to 52 patients; 2 patients were excluded due to protocol violations. Ten patients had a history of pancreatectomy (7 were treated with CREON) In this study, patients received placebo for 5 days (run-in period), followed by pancreatic enzyme replacement therapy as directed by the investigator for 16 days; this was followed by randomization to CREON or matching placebo for 7 days of treatment (double-blind period). Only patients with CFA less than 80% in the run-in period were randomized to the double-blind period All patients were to consume a high-fat diet (greater than or equal to 100 grams of fat/day) during the treatment period. The dosage of CREON during the double-blind period was 72,000 lipase units per main meal (3 main meals) and 36,000 lipase units per snack (2 snacks) [approximately 1,000 lipase units/kg/meal]

For chronic pancreatitis, the treatment involves pancreatic enzyme replacement therapy, such as CREON (pancrelipase), to improve fat absorption. The recommended dosage is 72,000 lipase units per main meal and 36,000 lipase units per snack, with patients consuming a high-fat diet during treatment. Key points to consider:

• Pancreatic enzyme replacement therapy is essential for managing exocrine pancreatic insufficiency due to chronic pancreatitis.
• CREON (pancrelipase) is a suitable treatment option, with a recommended dosage of 72,000 lipase units per main meal and 36,000 lipase units per snack.
• Patients should consume a high-fat diet during treatment to ensure adequate fat absorption.
• Monitoring of coefficient of fat absorption (CFA) is crucial to assess the effectiveness of treatment 2.

From the Research

Diagnosis and Treatment of Chronic Pancreatitis

• Chronic pancreatitis is a chronic inflammatory and fibrotic disease of the pancreas, with a prevalence of 42 to 73 per 100 000 adults in the United States 3.
• The diagnosis is based on pancreatic calcifications, ductal dilatation, and atrophy visualized by imaging with computed tomography, magnetic resonance imaging, or both 3.
• Endoscopic ultrasound can assist in making the diagnosis in patients with a high index of suspicion such as recurrent episodes of acute pancreatitis when imaging is normal or equivocal 3.

Management and Treatment Options

• The first line of therapy consists of advice to discontinue use of alcohol and smoking and taking analgesic agents (nonsteroidal anti-inflammatory drugs and weak opioids such as tramadol) 3.
• A trial of pancreatic enzymes and antioxidants (a combination of multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients 3.
• Patients with pancreatic ductal obstruction due to stones, stricture, or both may benefit from ductal drainage via endoscopic retrograde cholangiopancreatography (ERCP) or surgical drainage procedures 3.
• Different treatment options for pain consist of medical therapy, endoscopy or surgery, with their related merits and drawbacks discussed in the literature 4.

Lifestyle Interventions and Dietary Supplements

• Avoiding alcohol consumption and smoking are crucial lifestyle interventions for people with chronic pancreatitis 5, 6.
• Dietary supplements such as pancreatic enzyme supplements, vitamin/antioxidant supplements, and calcium supplements may be effective in managing symptoms 5, 6.
• A low-fat diet may also be beneficial for patients with chronic pancreatitis 5, 6.

Interdisciplinary Approach to Management

• Management of chronic pancreatitis requires an interdisciplinary approach including primary care practitioners, gastroenterologists, surgeons, radiologists, pain specialists, and nutritional therapists 7.
• Patients with chronic pancreatitis should be seen at least once a year and re-evaluated for causal risk factors, symptom control, and complications such as malnutrition, pancreatic exocrine insufficiency, and diabetes 7.