Pancreatic enzyme replacements

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. 

Pancreatic enzyme replacement is the mainstay of gastrointestinal therapy. Most enzyme products are formulated as capsules containing enteric-coated microspheres or microtablets to avoid inactivation of enzymes in the acidic stomach instead, they dissolve in the more alkaline environment of the duodenum. Capsules may be opened and the microbeads swallowed with food, as long as they are not chewed. A powder form is available for patients unable to swallow the capsules or microbeads, but bioavailability is poor. While products may contain similar enzyme ratios, they are not bioequivalent and cannot be substituted. Generic enzyme products generally display poor dissolution and should not be used.5 Table 13-3 lists commonly used enzyme replacement products. 

TABLE 13-3. Common Pancreatic Enzyme Replacement Products... 

Laboratory testing confirms the diagnosis of CF, and Jessica has been referred to her regional CF center for treatment. Additional stool studies indicate the presence of severe fat maldigestion. The pulmonologist indicates that she would like to start Jessica (weight 8.2 kg) on pancreatic enzyme replacement therapy. 

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. 

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. 

Pancreatic lipase is rapidly inactivated at pH values less than 4 [25] (Figs. 3 and 5], which has important consequences in the development of galenic formulations for pancreatic enzyme replacement. 

Zentler-Munro, P.L. et at (1987) Review pancreatic enzyme replacement -applied physiology and pharmacology. Aliment. Pharmacol. Then. 1. 575-591. Hernandez. L. et al. (1992) Recombinant streptokinase for the treatment of thrombotic disorders. Ann. N. K Acad. Sci.. 667,424-427. 

Pancreatic enzyme replacement therapy. Curr. Gastroenterol. Rep. 3, 101—108. 

The treatment of gastrointestinal involvement ultimately is aimed at correcting the nutritional deficit present in many patients. In addition to pancreatic enzyme replacement and other drug therapy described below, nutritional supplementation is employed frequently. Nutritional interventions range from behavioral modification to nocturnal feedings via gastrostomies. ... 

Bruno MJ, Rauws EAJ, Hoek FJ, et al. Comparative effects of adjuvant cimetidine and omeprazole during pancreatic enzyme replacement therapy. Dig Dis Sci 1994 39 988-992. 

---