Pancreatic Enzyme Replacement Therapy During Pancreatic Insufficiency

Abstract

Pancreatic stimulation and therefore digestion is a tightly controlled and hormonally mediated process. Any alterations affecting any of the systematic steps for successful digestion and absorption to occur will impair appropriate pancreatic enzymatic secretion, entry into the bowel lumen, functionality once inside the lumen, and thus appropriate mixing with foods and nutrients. Many causes of pancreatic insufficiency may require the initiation of pancreatic enzyme therapy, including but not limited to cystic fibrosis, pancreatic cancer, acute and chronic pancreatitis, and pancreatic surgery. This purpose of this article is to help clarify the conditions that cause pancreatic insufficiency, how to determine if the patient is malabsorbing, and the best use of pancreatic enzyme replacement therapy for treatment in these conditions. The first step in determining if pancreatic enzyme therapy is appropriate is to determine if the patient is malabsorbing specifically due to pancreatic exocrine insufficiency. An overview of the methods used to determine pancreatic insufficiency is provided, as well as appropriate treatment methods. Recent Food and Drug Administration regulations require a more thorough process, including randomized controlled trials to prove the safety and efficacy of pancreatic enzymes, to approve them for use. The studies used to verify efficacy also are examined. Last, dosing guidelines and some unconventional ways to administer pancreatic enzymes, such as during enteral feedings, are reviewed.

Effective and safe proton pump inhibitor therapy in acid-related diseases – A position paper addressing benefits and potential harms of acid suppression

“…These recommendations encompass the main diseases associated with exocrine pancreatic insufficiency (like acute pancreatitis, chronic pancreatitis, pancreatic cancer, cystic fibrosis, celiac disease, irritable bowel syndrome, etc. ), defined as an inadequate pancreatic enzyme activity to digest food, generally due to either insufficient enzyme production, insufficient enzyme activation, or to early enzyme degradation [386, 392]. …”

Total Pancreatectomy With Islet Autotransplantation

“…Data on gastric motility after non-TPIAT pancreatic surgery demonstrates delayed gastric emptying (DGE) in 45 to 50% of CP patients, and in 14 to 20% of post-pancreatectomy patients (58-62). An internal review at Johns Hopkins showed that 40% of patients experienced DGE post-TPIAT.…”

“…The pancreas plays an essential role in the digestion and absorption of nutrients (62, 63). CP may lead to malnutrition by multiple mechanisms, including malabsorption, decreased intake for fear of exacerbating pain, dietary restrictions, nausea, or gastric emptying problems.…”

Total Pancreatectomy With Islet Autotransplantation

“…58–62 Data on gastric motility after non-TPIAT pancreatic surgery demonstrate delayed gastric emptying in 45% to 50% of patients with CP, and in 14% to 20% of patients after pancreatectomy. 59–63 An internal review at Johns Hopkins showed that 40% of patients experienced delayed gastric emptying after TPIAT. Nausea, vomiting, poor oral intake, and constipation are common problems in both patients with CP and those after TPIAT.…”

“…63,64 CP may lead to malnutrition by multiple mechanisms, including malabsorption, decreased intake for fear of exacerbating pain, dietary restrictions, nausea, or gastric emptying problems. CP may lead to EPI.…”