Chronic Pancreatitis
Inadequate dosing of PERT is prevalent among patients with chronic pancreatitis and EPI. For example, Sikkens et al. conducted an anonymous survey of 176 Dutch patients with chronic pancreatitis and found that the median enzyme intake was six capsules per day (25 000 Units lipase per capsule), 25% of patients took three or fewer capsules, and 70% of patients reported steatorrhea-related symptoms, despite treatment. The survey method had many shortcomings (no data on how or when the capsules were taken, no quantification of supposed steatorrhea, etc). Nevertheless, the presence of significant symptoms is not surprising, as the patients were taking doses of pancreatin that would not correct steatorrhea. On the basis of gastrointestinal intubation and fat balance studies performed in persons with severe chronic pancreatitis and EPI the minimal dose of lipase which may correct steatorrhea is 90 000 USP U with meals (~3–4 capsules per meal), 10% of the normal prandial lipase output of 900 000 USP U.
The benefit of 90 000 USP U of pancreatin [two capsules of CREON (Abbott Laboratories, Abbott Park, Illinois) 40 000 containing 45 000 USP U lipase with meals and one capsule with snacks] compared with placebo was assessed in a multicenter, randomized controlled trial (RCT) in 62 patients with chronic pancreatitis and a coefficient of fat absorption (CFA) less than 80%. Pancreatin increased the CFA from 66.5 to 86.1% (mean change of CFA vs. placebo, 18.5 vs. 4.1%; P = 0.001) and the coefficient of nitrogen absorption (CNA) from 78.8 to 83.8% (mean change of CNA vs. placebo 4.7 vs. 0.8%; P = 0.005) and decreased stool frequency and weight. Of note ~35% of patients were on a proton pump inhibitor. Similar to a histamine H2-receptor antagonist, proton pump inhibitors likely alleviate fat malabsorption if 90 000 USP U [30 000 international units (IU)] of pancreatin are ingested with meals containing 25 g of fat by producing postprandial intraduodenal lipase concentrations of 75 USP U/ml (25 IU/ml), the concentration that corrects steatorrhea.
Differentiation Between Pancreatic Cancer and Chronic Pancreatitis
Inadequate dosing of PERT is prevalent among patients with chronic pancreatitis and EPI. For example, Sikkens et al. conducted an anonymous survey of 176 Dutch patients with chronic pancreatitis and found that the median enzyme intake was six capsules per day (25 000 Units lipase per capsule), 25% of patients took three or fewer capsules, and 70% of patients reported steatorrhea-related symptoms, despite treatment. The survey method had many shortcomings (no data on how or when the capsules were taken, no quantification of supposed steatorrhea, etc). Nevertheless, the presence of significant symptoms is not surprising, as the patients were taking doses of pancreatin that would not correct steatorrhea. On the basis of gastrointestinal intubation and fat balance studies performed in persons with severe chronic pancreatitis and EPI the minimal dose of lipase which may correct steatorrhea is 90 000 USP U with meals (~3–4 capsules per meal), 10% of the normal prandial lipase output of 900 000 USP U.
The benefit of 90 000 USP U of pancreatin [two capsules of CREON (Abbott Laboratories, Abbott Park, Illinois) 40 000 containing 45 000 USP U lipase with meals and one capsule with snacks] compared with placebo was assessed in a multicenter, randomized controlled trial (RCT) in 62 patients with chronic pancreatitis and a coefficient of fat absorption (CFA) less than 80%. Pancreatin increased the CFA from 66.5 to 86.1% (mean change of CFA vs. placebo, 18.5 vs. 4.1%; P = 0.001) and the coefficient of nitrogen absorption (CNA) from 78.8 to 83.8% (mean change of CNA vs. placebo 4.7 vs. 0.8%; P = 0.005) and decreased stool frequency and weight. Of note ~35% of patients were on a proton pump inhibitor. Similar to a histamine H2-receptor antagonist, proton pump inhibitors likely alleviate fat malabsorption if 90 000 USP U [30 000 international units (IU)] of pancreatin are ingested with meals containing 25 g of fat by producing postprandial intraduodenal lipase concentrations of 75 USP U/ml (25 IU/ml), the concentration that corrects steatorrhea.