Lipase pancreatic enzyme supplements

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 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. 

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. 

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. 

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. 

Pancreatic enzyme supplements are used to treat people who lack pancreatic secretions. Pancreatm, the British Pharmacopoeia standard, is an extract of pancreas, and contains enzymes with proteinase, amylase, and lipase activity most commercial formulations are similar or identical (SEDA16, 358). 

The effect of oral pancreatic enzyme supplementation (Creon 10 000 in a dose of 1000 units of lipase per gram of ingested dietary fat) on fat malabsorption has been evaluated in an open study in 24 patients with HIV infection (1). Pancreatic enzyme supplementation was highly effective in reducing fecal fat loss. There were no clinical adverse effects or changes in serum biochemistry attributable to the drug. 

Pancreatic enzyme supplementation and a reduction of dietary fat are used to treat malabsorption and steatorrhea. An initial lipase dose of about 30,000 international units should be given with each meal. 

Most patients with malabsorption will require pancreatic enzyme supplementation and a reduction in dietary fat in order to achieve satisfactory nutritional status and become relatively asymptomatic. An initial prandial dose of 30,000 international units of lipase (uncoated tablet, capsule, or powder) is recommended to be given with each meal (see Fig. 34—5). Alternatively, the use of microencapsulated enteric-coated dosage forms may be used. The total daily lipase dose should be titrated to reduce steatorrhea. In some patients a reduction in dietary fat may be necessary. The addition of an antisecretory drug should be reserved for patients resistant to enzyme therapy (see Fig. 39-5). If these measures are ineffective, documentation of the diagnosis and exclusion of other diseases should be undertaken. 

Oral pancreatic enzyme supplements are available as a powder, uncoated or coated tablet, capsule, enteric-coated sphere (ECS) and microsphere (ECMS), or enteric-coated microtablet (ECMT) encased in a cellulose or gelatin capsule (Table 39-8). Recommended dosages of microencapsulated enteric-coated products are not necessarily more effective than recommended dosages of the non-enteric-coated enzyme preparations. This is because a lesser quantity of lipase is usually administered at each meal with the enteric-coated preparations. 

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. 

Drug formulations Impaired digestion in cystic fibrosis affects about 90% of patients. As soon as pancreatic insufficiency is identified, enzyme supplementation is prescribed, even for breast fed infants. In a prospective, randomized study 40 infants and toddlers were treated with Creon for children, a formulation that contains smaller granules and is administered with a dosing spoon (5000 lipase units per scoop) and Creon 10 000 for 2 weeks each in a crossover design [113 ]. The former was superior in terms of parents preference, but equally effective with regard to fat absorption. Three patients who took Creon for children had treatment-related adverse events abdominal pain, constipation, vomiting, with one withdrawal) compared with one who took Creon 10 000 (severe diaper dermatitis/nappy rash). 

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