Pancreatic Enzyme Therapy

Background: Treatment with pancreatic enzymes must be based on an understanding of the normal physiology and pathophysiology of exocrine pancreatic function, as well as of the diseases that cause exocrine pancreatic insufficiency of either a structural or a functional type. These include chronic pancreatitis, pancreatic cancer, cystic fibrosis, pancreaticocibal asynchrony after gastric or pancreatic surgery, and celiac disease.

Methods: Selective review of the literature.

Results: Exocrine pancreatic insufficiency can cause meteorism, diarrhea, steatorrhea, and weight loss. All of these manifestations are non-specific except steatorrhea. Enzyme supplementation is indicated only for the treatment of demonstrated pancreatic dysfunction; unfortunately, however, no sensitive and specific pancreatic function tests are currently available. As a result, pancreatic enzyme supplementation is considered to be indicated on pragmatic grounds when, for example, the patient is suffering from diarrhea and weight loss and has been demonstrated to have a disease leading to exocrine pancreatic insufficiency. To be acceptable for clinical use, a pancreatin preparation must satisfy the following criteria: it must be enterically coated, so that it will not be destroyed by gastric acid; mix well with gastric chyme; exit the stomach simultaneously with chyme; and be rapidly released from its enteric coating upon entering the duodenum. Although there have been no large-scale, randomized comparative studies of different types of pancreatin preparation, the current clinical preference is for enterically coated micropellets or minitablets with a diameter of 2 mm or less. The initial dosage is 20 000 to 40 000 units of lipase taken once or twice per meal, with dose adjustment afterward as needed. The dose can be raised, and a proton-pump inhibitor can be added on.

Conclusion: There is still no simple test that can be used to diagnose pancreatic exocrine insufficiency with certainty. The treatment is symptomatic; its goals are to lessen steatorrhea and reverse weight loss.