What are the long-term treatment options for chronic pancreatitis?

From the Guidelines

The long-term treatment for chronic pancreatitis should prioritize surgical intervention over endoscopic therapy for patients with painful obstructive chronic pancreatitis, as it is considered the most effective approach for managing pain and improving quality of life 1.

Key Components of Treatment

• Pain management: a step-wise approach starting with acetaminophen or NSAIDs, progressing to weak opioids like tramadol, and then stronger opioids if needed
• Pancreatic enzyme replacement therapy (PERT): essential for digestive issues, with products like Creon or Zenpep taken with meals at doses of 25,000-40,000 lipase units per main meal and half that for snacks
• Nutritional support: a low-fat diet (less than 30% of calories from fat), abstinence from alcohol, smoking cessation, and management of diabetes with insulin or oral medications as needed

Considerations for Treatment

• Endoscopic procedures may be necessary for strictures or stones, but are generally considered a less effective alternative to surgery for long-term treatment 1
• Surgery, such as the Frey procedure or total pancreatectomy with islet autotransplantation, is reserved for severe cases not responding to medical management
• Nutritional counselling and substitution of pancreatic enzymes are crucial for managing exocrine pancreatic insufficiency, with a focus on reducing steatorrhoea and achieving adequate energy intake 1

Additional Considerations

• Patients with chronic pancreatitis should be considered at risk for malnutrition and osteoporosis, and preventive measures should be taken 1
• A comprehensive approach addressing the underlying inflammation and fibrosis of the pancreas is necessary to improve quality of life and prevent further pancreatic damage

From the FDA Drug Label

A randomized, double-blind, placebo-controlled, parallel group study was conducted in 54 adult patients, aged 32 to 75 years, with exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatectomy (Study 4) The mean change in CFA from the run-in period to the end of the double-blind period in the CREON and placebo groups is shown in Table 3 Table 3: Change in Coefficient of Fat Absorption in Adults with Exocrine Pancreatic Insufficiency Due to Chronic Pancreatitis and Pancreatectomy (Study 4) CREON N = 24Placebo N = 28 CFA [%] Run-in Period (Mean, SD) 54 (19) 57 (21) End of Double-Blind Period (Mean, SD) 86 (6) 66 (20) Change in CFA * [%] Run-in Period to End of Double-Blind Period (Mean, SD) 32 (18) 9 (13) Treatment Difference (95% CI) 21 (14,28)

Long-term treatment for chronic pancreatitis involves the use of pancreatic enzyme replacement therapy, such as CREON (pancrelipase), to improve fat absorption and manage symptoms.

• The study results show that CREON is effective in improving coefficient of fat absorption (CFA) in patients with exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatectomy.
• The recommended dosage of CREON is 72,000 lipase units per main meal and 36,000 lipase units per snack.
• Patients should consume a high-fat diet during treatment.
• The mean exposure to CREON in the study was 7 days.
• Subgroup analyses showed that mean change in CFA was greater in patients with lower run-in period CFA values than in patients with higher run-in period CFA values 2.

From the Research

Long-term Treatment for Chronic Pancreatitis

• The management of chronic pancreatitis involves a multimodal approach, including nutrition optimization, pain management, and when indicated, endoscopic and surgical intervention 3.
• First-line 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) 4.
• A trial of pancreatic enzymes and antioxidants (a combination of multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients 4.
• 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 4.
• Surgery is superior to endoscopic interventions for long-term pain control, and early surgery (<3 years from symptom onset) has more superior outcomes than late surgery 5, 3.

Nutrition Management

• Nutrition deficiencies in chronic pancreatitis are common and can be atypical in nature, requiring individualized management for patients 6.
• The etiology of nutrition deficiencies in chronic pancreatitis is multifactorial and includes aspects of exocrine and/or endocrine dysfunction, significant abdominal pain, often persistent alcohol consumption, and increased metabolic activity 6.
• Supplemental enzymes should be given to patients with exocrine insufficiency to avoid malnutrition 3.

Pain Management

• Pain control remains central to the overall management of chronic pancreatitis, and most strategies aimed at treating pain are based on expert opinion 7.
• Safe opioid practices should be incorporated into pain management strategies, including prescription monitoring practices 7.
• Nonsurgical options for pain control include behavior modification (smoking cessation, alcohol abstinence), celiac plexus block, splanchnicectomy, nonopioid pain medication, and opioids 3.