Pancreatic enzyme treatment in chronic pancreatitis: Quality of management and adherence to guidelines–A cross‐sectional observational study

Abstract

Objectives Pancreatic exocrine insufficiency (PEI) is a common complication in patients with chronic pancreatitis (CP), leading to increased morbidity and mortality if not treated adequately. Pancreatic enzyme replacement therapy|pancreas enzyme replacement therapy (PERT) is the cornerstone in treatment of patients with PEI. In the present study, we use data from the Scandinavian Baltic Pancreatic Club database to examine adherence of PERT according to United European Gastroenterology evidence‐based guidelines treatment of CP. Patients and methods Patients with definitive or probable CP according to M‐ANNHEIM diagnostic criteria were included. We collected information on exposures, exocrine function, intake of pancreatic enzymes, and markers of nutrition. Fecal elastase <200 μg/g was defined as a marker for PEI. Enzyme replacement therapy of 100,000 lipase units or more was defined as adequate treatment. Results We included 1006 patients from 8 centers in five countries. Sixty‐four percent of the patients were correctly treated. Twenty‐five per cent of PEI patients were not taking enzymes at all, and 20% of PEI patients were undertreated with insufficient PERT doses according to the guidelines. Fourteen percent of patients with sufficient pancreatic function were receiving enzymes despite normal exocrine pancreatic function. There were center differences. Current smoking was associated with lack of treatment and alcohol abuse was associated with under‐treatment. There were no associations between “no treatment” or “under‐treatment” for underweight or vitamin D deficiency. Conclusion In our CP expert centers, the adherence to guidelines for enzyme treatment is insufficient. Both patient factors and center differences have influence on treatment adherence.

Exocrine pancreatic insufficiency and pancreatic exocrine replacement therapy in clinical practice

“…In addition to PERT improving digestion and absorption in patients with EPI, studies have shown improvements in weight trends, quality of life, and even mortality in patients with chronic pancreatitis taking PERT. 45,[54][55][56] Several studies also found prolonged survival in patients with pancreatic cancer. [57][58][59] Giordano et al conducted a retrospective observational trial and demonstrated PERT and dietary interventions had a direct and significant impact on overall survival.…”

“…72 Studies have demonstrated a wide range of dosing practices and often found PERT was underutilized and inadequately dosed. 39,45,54,73 The American College of Gastroenterology recommends a starting dose of at least 40,000-50,000 USP units of lipase per meal. 60 Randomized controlled trials have found enzyme doses of 72,000-75,000 USP units of lipase with meals and 36,000-50,000 USP units of lipase with snacks to be effective for adequate fat absorption (see Table 4).…”

“…In addition to PERT improving digestion and absorption in patients with EPI, studies have shown improvements in weight trends, quality of life, and even mortality in patients with chronic pancreatitis taking PERT 45,54–56 . Several studies also found prolonged survival in patients with pancreatic cancer 57–59 .…”

Underutilization of pancreatic enzyme replacement therapy in pancreatic cancer and chronic pancreatitis

“…However, despite known benefits, infrequent prescription and underuse of PERT are common [6]. Existing studies also show that adherence to evidence-based guidelines in the medical management of EPI remains suboptimal [7][8][9]. Therefore, we sought to analyze various factors associated with the use of PERT in patients with EPI.…”

Optimizing management of patients with pancreatic exocrine insufficiency

“…Patients with PEI can present with non-specific gastrointestinal (GI) symptoms suggesting maldigestion, including steatorrhea, weight loss, abdominal pain, and bloating ( 2 ). Due to the character of the symptoms, as well as to the potential diversity of the underlying disease, PEI is underdiagnosed, instauration of treatment may be delayed, and overall management not optimal ( 3 , 4 ). Furthermore, PEI can have a negative impact of outcome ( 5 ) and pancreatic enzyme replacement therapy (PERT) can improve both survival and quality of life (QoL) ( 6 , 7 ).…”