Pancreatic enzyme supplementation

Choose appropriate pancreatic enzyme supplementation for patients with chronic pancreatitis. 

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. 

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). 

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

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. 

Colonic toxicity due to pancreatic enzyme supplements in children with cystic fibrosis has been reviewed (3). Since it was first reported in 1994, an increasing number of cases of fibrosing colonopathy due to pancreatic enzymes have been reported in children with cystic fibrosis in the UK, USA, and continental Europe. The disorder is not affected by age or sex, and the age at diagnosis is 9 months to 13 years. 

The major application of the assays that measure CHY activity in stool is in the investigation of chronic pancreatic insufficiency. CHY in feces is often reduced below the lower reference limit in such subjects in whom steatorrhea has developed, but it is not usefid in identifying subjects with early pancreatic insufficiency. (See Table 48-15.) CHY measurement in patients with chronic pancreatic insufficiency treated with oral pancreatic enzyme supplements may indicate whether the therapy is adequate or whether increased supplementation is necessary. 

Amarri S, Harding M, Coward WA, Evans TJ, Weaver LT. C-mixed triglyceride breath test and pancreatic enzyme supplementation in children with cystic fibrosis. Arch Dis Childhood 1997 76 349-51. 

FitzSimmons SC, Burkhart GA, Borowitz D, et al. High-dose pancreatic-enzyme supplements and fibrosing colonopathy in children with cystic fibrosis. N Engl J Med 1997 336 1283-1289. 

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. 

Symptomatic patients whose steatorrhea is not corrected by pancreatic enzyme supplementation and a reduction in dietary fat may benefit from the addition of an H2-receptor antagonist or a proton pump inhibitor. An H2-receptor antagonist should be used before trying a proton pump inhibitor. 

The majority of patients with alcohol-related CP require pain control and pancreatic enzyme supplementation. " Avoidance... 

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