Treatment

Pancreatic enzyme replacement therapy (PERT) is the main treatment for PEI. The objective is to deliver sufficient enzymatic activity into the duodenal lumen as simultaneously as possible with the meal in order to restore nutrient digestion and aid absorption.1

  • Orally administered enzymes facilitate the digestion of fats, proteins and carbohydrates to replace the missing pancreatic digestive enzymes1
  • Management of PEI may extend beyond PERT to include the following:2,3
    • Lifestyle modifications (e.g. frequent and low-volume meals; avoiding food that is difficult to digest; limitation of alcohol intake; cessation of smoking) 
    • Vitamin supplementation (primarily the fat-soluble vitamins A, D, E, and K)

FACT

The objective of Pancreatic Enzyme Replacement Therapy (PERT) is to deliver sufficient enzymatic activity into the duodenal lumen at the same time as the meal, in order to restore nutrient digestion and aid absorption.

Smith RC, et al. 20151

How does PERT work?4

PERT Dosing

The correct PERT dose is essential for effective treatment.

Dosing varies from individual to individual, depending on the degree of maldigestion and fat content of the meal.4

Individualising the PERT dose

While different patients may have the same or similar starting doses, the dose should be titrated according to the individual’s response and experience.

  • Titration may be discussed with the patient when prescribing and at follow up

New onset and changes of abdominal symptoms should be reviewed to exclude the possibility of colonic damage - especially if the patient is taking in excess of 10,000 units of lipase/kg/day.9-12

To help patients understand their dose, they should understand the rationale behind PERT dosing, including the relevance to physiological pancreatic enzyme production.4,13

The rationale for PERT

The healthy pancreas releases approximately 720,000 lipase units in response to a 300‒600 kcal meal, with approximately 10% needed to maintain normal digestion.4 PERT aims to mimic the exocrine secretory response of the healthy pancreas by replacing the digestive enzymes – lipase, amylase and protease – in people with PEI whose pancreas can no longer produce adequate amounts.1

Lipase secretion by a healthy pancreas in response to a stimulus of a 300-600 kcal meal:4

Dosing of PERT in infants and children

Initially 5,000 lipase units should be taken with each feed. If required, dose increases should be added slowly, with careful monitoring of response and symptoms. 15

In infants and children, the maximum dose recommendation is 10,000 units of lipase per kilogram per day.1,9

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Professor Domínguez-Muñoz

Director, Department of Gastroenterology, University Hospital of Santiago de Compostela, Spain

The views expressed are of the healthcare professional and not the hospital where they work

Early detection and optimum treatment of PEI are essential to relieve symptoms and normalise nutritional status1,14

References

  1. Smith RC, Smith SF, Wilson J, Pearce C, Wray N, Vo R, et al. Australasian guidelines for the management of pancreatic exocrine insufficiency. Australasian Pancreatic Club, October 2015. pp 1–122.
  2. Domínguez-Muñoz JE. Pancreatic exocrine insufficiency: diagnosis and treatment. J Gastroenterol Hepatol. 2011;26(Suppl 2):12- 16.
  3. Löhr JM, Oliver MR, Frulloni L. Synopsis of recent guidelines on pancreatic exocrine insufficiency. United European Gastroenterology Journal. 2013;1:79-83
  4. Keller J, Layer P. Human pancreatic exocrine response to nutrients in health and disease. Gut. 2005;54(Suppl 6):vi1-28.
  5. Löhr JM, Dominguez-Munoz E, Rosendahl J, et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). United European Gastroenterol J. 2017;5(2):153-199.
  6. Sikkens EC, Cahen DL, Kuipers EJ, et al. Pancreatic enzyme replacement therapy in chronic pancreatitis. Best Pract Res Clin Gastroenterol. 2010;24:337-47.
  7. Imrie CW, Connett G, Hall RI, et al. Review article: enzyme supplementation in cystic fibrosis, chronic pancreatitis, pancreatic and periampullary cancer. Aliment Pharmacol Ther. 2010;32(Suppl 1):1-25.
  8. de-Madaria E, Abad-González A, Aparicio J R, et al. The Spanish Pancreatic Club’s recommendations for the diagnosis and treatment of chronic pancreatitis: Part 2 (treatment). Pancreatology. 2013;1:18-28.
  9. Creon® 10000 Capsules Summary of Product Characteristics. Available from: www.medicines.org.uk/emc/medicine/2068/SPC Last accessed November 2017.
  10. Nutrizym 22 Summary of Product Characteristics. Available from: www.medicines.org.uk/emcmobile/medicine/1154/spc Last accessed: November 2017.
  11. Pancrease HL Capsules Summary of Product Characteristics. Available from: www.medicines.org.uk/emc/medicine/7363/spc Last accessed: November 2017.
  12. Pancrex V Capsules Summary of Product Characteristics. Available from: www.medicines.org.uk/emc/medicine/1411/SPC Last accessed: November 2017.
  13. Domínguez-Muñoz JE. Pancreatic enzyme therapy for pancreatic exocrine insufficiency. Gastroenterol Hepatol (N Y). 2011;7:401-3.
  14. Suleiman SL, Kadiyala V, Conwell DL. Pancreatic exocrine insufficiency. Part 1 of 2: Pathogenic and Diagnostic Considerations. Gastroenterology and Endoscopy News, Special Edition, 2012. pp51-56. Available from: http://www.gastroendonews.com/ download/Pancre_CaPart1GENSE12_WM.pdf. Last accessed: November 2017.
  15. Creon Micro Summary of Product Characteristics. Available from : https://www.medicines.org.uk/emc/product/5564/smpc Last accessed: November 2017