What to Do when a Patient with Exocrine Pancreatic Insufficiency Does Not Respond to Pancreatic Enzyme Substitution

Abstract

In the majority of patients, pancreatin microsphere preparations containing 25,000–40,000 FIP units of lipase will lead to a clinical improvement and reduction of steatorrhea in patients with exocrine pancreatic insufficiency. In patients failing to respond, the following stepwise procedure is recommended: increasing enzyme dosage; checking the patient’s compliance; reevaluating the diagnosis; and as a last resort to decrease fat intake or adding H₂-blockers or proton pump inhibitors. Although this stepwise procedure is time-consuming, it is necessary to prevent in patients not responding to pancreatic enzyme substitution the development of late complications of exocrine pancreatic insufficiency.

Nutrient Deficiency and Supplementation in Chronic Pancreatitis

“…19 Reasons that steatorrhea persists in CP patients include patient compliance factors, incorrect diagnosis due to lack of identification of other possible etiologies (ie, bacterial overgrowth), inadequate doses of enzymes, decreased bioavailability (destroyed by acid environment), asynchrony of gastric empty rate of food and pancreatic enzymes. 2,12,21 Optimizing enzyme therapy is the primary treatment for fat malabsorption.…”

“…2 Dosing varies; Lankisch 21 recommends microcapsulated, enteric-coated (1.4 mm, pH 5.5) taken with meals 25 000-40 000 units/meal to start and increase dose to 2 to 3 times the initial dose, if steatorrhea persists. 21 4. Educate about medications: Depending on the prescription some patients have a high pill burden that can decrease success due to noncompliance.…”

Delayed release pancrelipase for treatment of pancreatic exocrine insufficiency associated with chronic pancreatitis

“…55,102 In compliant patients not responding to PES, increasing the dose of PES by 2-3 fold along with distribution of calories across 5-6 smaller meals is …”

Management of Chronic Pancreatitis

“…It has been shown that the use of gelatin capsules of pancreatic microsphere containing supplements, containing 25,000 to 40,000 units of lipase will lead to a significant reduction of steatorrhea in patients with CP. 36 In those patients who fail pancreatic enzyme therapy, a gastric acid suppressing agent, such as a proton pump inhibitor, should be added to inhibit gastric acid degradation of orally ingested pancreatic enzymes.…”