Enzyme pancreatic, supplements

Fecal elastase 1 concentration can be measured by an ELISA test kit using an antibody specific for the human enzyme pancreatin supplements do not interfere with this pancreatic function test and need not be discontinued. Although measurement of fecal elastase 1 excretion appears to be somewhat more sensitive than fecal chymotrypsin, its specificity and positive predictive value are similarly low, and falsepositive results can be expected in patients with intestinal diseases. Conversely, mild-to-moderate stages of pancreatic exocrine insufficiency cannot be diagnosed reliably. 

Q14 Pancreatic enzyme preparations contain amylase, lipase and protease enzymes. These supplements are given by mouth and compensate for the reduced or absent pancreatic secretions they assist the digestion of starch, fat and protein. Since the enzymes may be inactivated by gastric acid, they are usually presented in a protected, enteric-coated form which is sprinkled directly on the food. 

The dose of pancreatic supplement is usually gradually increased during the initial stages of treatment until objective measures of fat absorption indicate a 90% fat uptake. In practice, the dose of pancreatin for each meal is divided into two parts, with half given at the start of the meal and half at the middle. Enzymes must also be taken with snacks, including milk. Children can often swallow capsules by the age of 5 years. For younger children, the enzymes are taken out of the capsule and mixed with liquid, fruit puree, or soft fruit. 

Maximizing nutritional status through pancreatic enzyme replacement and vitamin and nutritional supplements is necessary for normal growth and development and for maintaining long-term lung function. 

Choose appropriate pancreatic enzyme supplementation for patients with chronic pancreatitis. 

Treatment of chronic pancreatitis is aimed at removing the cause (ethanol abuse or biliary stones), providing analgesia, supplementing with pancreatic enzyme preparations, and implementing dietary restrictions. 

Supplementation with pancreatic enzymes may reduce the pain and fatty diarrhea associated with chronic pancreatitis (Table 20-3). Best results are achieved in patients who have mild non-alcoholic pancreatic disease. Common pancreatic enzyme supplements contain lipase, amylase, and protease in varying proportions. Thus, the dose can be tailored to the patient s requirement for exogenous enzyme supplementation and response to therapy. 

Non-enteric-coated pancreatic enzyme supplements require high doses to compensate for loss of enzyme due to... 

Non-enteric-coated pancreatic enzyme supplements can be used for initial therapy. The relative dose of amylase, lipase, and protease may be increased until control of pain and fatty diarrhea is achieved or the patient experiences intolerable side effects. If pain and diarrhea control are achieved, the patient can be transitioned to an enteric-coated supplement to maximize compliance. A reasonable example starting regimen is Viokase-8, six tablets with each meal and at bedtime, given with famotidine 20 mg at bedtime. 

Most pancreatic enzyme supplements are enteric coated to release enzymes in the alkaline environment of the intestine this minimizes enzyme destruction in the stomach. Enteric-coated pancreatic enzyme supplements require fewer daily dosage units, but delivery of the drug to the site of action and effectiveness may be delayed by gastric emptying time.41... 

Pancreatic enzyme supplements should be taken immediately prior to meals to aid in the digestion and absorption of food. Alternately, patients can supplement their diet with medium chain triglycerides (MCTs) or ingest foods rich in MCTs since they do not require pancreatic enzymes for absorption. An appropriate regimen incorporates the successful doses of each enzyme (amylase, lipase, and protease) from the starting non-enteric-coated regimen. As with the previous example, a patient stabilized on Viokase-8, six tablets with each meal, can be transitioned to Pancrease MT-16 three tablets with meals. The famotidine can then be discontinued. 

Educate patients that compliance with and proper use of dietary pancreatic enzyme supplementation is key to improved... 

Optimize pancreatic enzyme supplementation, starting first with a non-enteric-coated enzyme supplement and an H2RA. When pain and diarrhea are stabilized, consider switching to an enteric-coated enzyme supplement for ease of dosing. 

Develop a plan for reassessing pancreatic enzyme supplementation and analgesia on an outpatient basis. 

Most patients with malabsorption require pancreatic enzyme supplementation (Fig. 28-2). The combination of pancreatic enzymes (lipase, amylase, and protease) and a reduction in dietary fat (to less than 25 g/meal) enhances nutritional status and reduces steatorrhea. An initial dose containing about 30,000 international units of lipase and 10,000 international units of trypsin should be given with each meal. 

Oral pancreatic enzyme supplements are available as powders, uncoated or coated tablets, capsules, enteric-coated spheres and microspheres, or enteric-coated microtablets encased in a cellulose or gelatin capsule (Table 28-2). Microencapsulated enteric-coated products are not superior to recommended doses of conventional non-enteric-coated enzyme preparations. The quantity of active lipase delivered to the duodenum appears to be a more important determinant in pancreatic enzyme replacement therapy than the dosage form. GI side effects appear to be dose related but occur less frequently with enteric-coated products. 

The effectiveness of pancreatic enzyme supplementation is measured by improvement in body weight and stool consistency or frequency. The 72-hour stool test for fecal fat may be used when the adequacy of treatment is in question. 

Pancreatic enzyme replacement or supplement when enzymes are absent or deficient, such as with chronic pancreatitis, cystic fibrosis, or ductal obstruction from cancer of the pancreas or common bile duct to reduce malabsorption treatment of steatorrhea associated with bowel resection or postgastrectomy syndrome PO 1-3 capsules ortablets before or with meals or snacks. May increase to 8 tablets/dose. 

Exocrine pancreatic insufficiency is most commonly caused by cystic fibrosis, chronic pancreatitis, or pancreatic resection. When secretion of pancreatic enzymes falls below 10% of normal, fat and protein digestion is impaired and can lead to steatorrhea, azotorrhea, vitamin malabsorption, and weight loss. Pancreatic enzyme supplements, which contain a mixture of amylase, lipase, and proteases, are the mainstay of treatment for pancreatic enzyme insufficiency. Two major types of preparations in use are pancreatin and pancrelipase. Pancreatin is an alcohol-derived extract of hog pancreas with relatively low concentrations of lipase and proteolytic enzymes, whereas pancrelipase is an enriched preparation. On a per-weight basis, pancrelipase has approximately 12 times the lipolytic activity and more than 4 times the proteolytic activity of pancreatin. Consequently, pancreatin is no longer in common clinical use. Only pancrelipase is discussed here. 

Pancreatic enzyme supplements are well tolerated. The capsules should be swallowed, not chewed, because pancreatic enzymes may cause oropharyngeal mucositis. Excessive doses may cause diarrhea and abdominal pain. The high purine content of pancreas extracts may lead to hyperuricosuria and renal stones. Several cases of colonic strictures were reported in patients with cystic fibrosis who received high doses of pancrelipase with high lipase activity. These high-dose formulations have since been removed from the market. 

C. J. Taylor and J. A. Dodge. High-strength pancreatic enzyme supplements and large-bowel stricture in cystic fibrosis. Lancet 5 110(1994). 

Pancreatic function tests are therefore indicated if and when one or more of the following aspects need be clarified Is a symptom or sign caused by pancreatic exocrine insufficiency Has pancreatic exocrine insufficiency developed in the course of chronic pancreatitis Does a patient require enzyme supplementation treatment ... 

Although all pancreatic enzymes are inactivated during intestinal transit, fecal outputs of several enzymes correlate with pancreatic enzyme secretion. Fecal chymotrypsin activity, which is comparatively stable in the lumen as well as in extracorporal fecal samples, can be measured by a commercially available photometric test kit. When performed on three consecutive days, this test detects severe pancreatic exocrine insufficiency, but sensitivity and specificity are low in mild-to-moderate cases. In addition, the test does not differentiate between porcine and human chymotrypsin, so that pan-creatin supplements need to be discontinued 5 days prior to the test. For this reason, however, the test is able to monitor a patient s compliance in severe pancreatic insufficiency appar-endy refractory to enzyme treatment. Patients... 

Keller J, Layer P Pancreatic enzyme supplementation therapy. Curr Treat Options Gastroenterol 6 369-374, 2003. 

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