Pancrelipase Therapy


Article Author:
Priyanka Venkatesh


Article Editor:
Anup Kasi


Editors In Chief:
Tod Aeby


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
1/8/2019 11:49:36 PM

Indications

Pancrelipase, which is a combination of lipase, protease, and amylase, has been shown to benefit patients with exocrine pancreatic insufficiency.[1]

The different conditions that are associated with pancreatic insufficiency that may require supplementation with pancrelipase are -

FDA-Approved

  • Chronic pancreatitis: Structural damage involving the pancreatic ducts and acinar cells which result from a prolonged inflammatory reaction in the pancreas is the most common cause of insufficiency[2]
  • Tumors: Obstruction of the pancreatic duct by a tumor in the pancreas/ampulla leads to atrophy causing enzyme deficiency[3]
  • Post surgery:
    • Pancreatic resection: Loss of glandular tissue or duct occlusion post-procedure[4]
    • Gastric resection: Insufficient mixing of chyme with pancreatic enzymes because of rapid gastric emptying[5]
    • Small bowel resection: Inadequate secretion of cholecystokinin-pancreozymin and secretin
    • Lymph node dissection: Postcibal asynchrony and decreased pancreatic stimulation
  • Genetic disorders:
    • Cystic fibrosis: An autosomal recessive disorder resulting from mutations in both copies of the gene for cystic fibrosis transmembrane conductance regulator (CTFR) on chromosome 7. The resultant protein regulates chloride and sodium transport across the endothelial cell membranes in exocrine glands. The major implication of this condition is the blockage of pancreatic ducts from the inspissated secretions resulting thereof[6]
    • Schwachman Diamond syndrome: An autosomal recessive disorder that presents in infancy. The usual presentation includes skeletal abnormalities, neutropenia, bone marrow dysfunction, and exocrine pancreatic insufficiency
    • Hereditary hemochromatosis: An autosomal recessive disorder resulting from mutations in the HFE gene coding for hepcidin, transferrin, hemojuvelin and ferroportin results in the increased absorption and deposition of iron in the body. Deposition of iron in the pancreas leads to reduced glandular function
    • Zollinger-Ellison syndrome: A rare condition resulting from the development of gastrinomas or gastrin-secreting tumors in the stomach and duodenum. About 30% of cases occur as a part of MEN1 syndrome which is inherited in an autosomal dominant fashion. Increased gastrin production leads to a suppression of pancreatic enzymes
    • Celiac disease: An autoimmune condition that may be inherited in either an autosomal dominant or recessive manner, may result in a decreased CCK secretion which secondarily results in reduced pancreatic secretion
    • Crohn's disease: An autoimmune condition that may cause the production of antibodies directed against the pancreas which interferes which enzyme production
    • Autoimmune pancreatitis: IgG4-related disease that eventually progresses to exocrine pancreas insufficiency

Non-FDA Approved

  • Enteral feeding tube occlusion: Administration of a pancreatic enzyme and sodium bicarbonate solution to blocked feeding tube was effective in relieving the obstruction. The efficacy was further improved by application of the solution closer to the clogged area using a catheter[7]

Mechanism of Action

The alkaline pH of the duodenum activates the components of pancrelipase which then help in digestion.

Lipase

  • Pancreatic lipase catalyzes the hydrolysis of triglycerides to monoglycerides, fatty acids, and glycerol. 
  • Colipase anchors the lipase to the lipid-water membrane of the micelle producing a change in the structure of that surface. The hydrophobic active site is thus exposed to the binding of the triglycerides and the subsequent interaction with the catalytic triad. There is hydrolyzation of the esters of the fatty acids.

Amylase

  • Pancreatic amylase hydrolyzes the alpha 1-4 linkages in the polysaccharides of three or more linked glucose units.
  • Starch is only reduced to a lower compound as alpha 1-6 linkages are not hydrolyzed. Therefore, starch is broken down into dextrins and lower sugars.

Protease

  • Pancreatic protease comprises trypsin and chymotrypsin which belong to the family of serine proteases
  • Trypsin acts on the arginine and lysine residues which are hydrophilic
  • Chymotrypsin acts on the hydrophobic residues tryptophan, tyrosine, and phenylalanine
  • Both components present a catalytic site formed by the triad of serine, histidine, and aspartate.

It, therefore, acts like the digestive enzymes inherently secreted by the pancreas in the absence of insufficiency

Various factors affect the efficacy of this supplementation, for example:

  • Dose
  • Gastrointestinal (GI) pH
  • Size of the micro-spherules

Pharmacokinetics

  • The enzymes are released only if the pH is greater than 5.5.
  • Some preparations are enteric coated which inhibit gastric inactivation during gastric passage and deliver more to the duodenum where it is active.
  • The GI tract does not absorb the contents in any amounts.
  • The drug is excreted in the feces.

Administration

Oral Administration

The oral preparation should not be kept in the mouth for prolonged periods as it tends to cause mucosal irritation and stomatitis.

Tablets 

  • Administered with a meal or immediately before it with sufficient fluids.
  • The tablet is not to be crushed or chewed.
  • To be taken whole along with a proton pump inhibitor (if not enteric-coated)

Enteric-Coated Capsules

  • Administered with a meal or immediately before it with sufficient fluids
  • The enteric coating is not to be destroyed; to be consumed whole
  • If the patient cannot swallow, the enteric-coated micro-spherules are to be removed from the capsule and mixed with small amount of acidic foods and administered

Other Routes of Administration

  • Gastrostomy tube: Factors to be considered include the size of the tube, size of the micro-spherules, feeding schedules and other concurrent medications to be administered
  • Jejunostomy or duodenostomy tube: The enteric coating is to be destroyed by crushing and then administered after mixing with sodium bicarbonate

Adverse Effects

Mild Adverse Reactions

  • Abdominal pain: Early 3% to 18%
  • Headache: Early 3% to 15%
  • Nasal congestion: Early 14%
  • Otalgia: Early 11%
  • Infection: Delayed 3% to 11%
  • Diarrhea: Early 10%
  • Dyspepsia: Early 10%
  • Cough: Delayed 4% to 10%
  • Flatulence: Early 3% to 9%
  • Pruritus ani: Early 7%
  • Epistaxis: Delayed 7%
  • Vomiting: Early 6%
  • Dizziness: Early 4%
  • Pharyngitis: Delayed 4%
  • Pruritus: Early 0% to 1%
  • Urticaria: Early 0% to 1%
  • Maculopapular rash: Early 0% to 1% 
  • Nausea: Early  Incidence not known
  • Muscle cramps: Delayed Incidence not known
  • Myalgia: Early Incidence not known
  • Lactose intolerance: Early Incidence not known

 Moderate Adverse Reactions

  • Lymphadenopathy: Delayed 11%
  • Cholelithiasis: Delayed 7%
  • Ascites: Delayed 7%
  • Peripheral edema: Delayed 3%
  • Anemia: Delayed 3%
  • Hyperglycemia: Delayed 2%
  • Hypoglycemia: Early 2%
  • Constipation: Delayed Incidence not known
  • Stomatitis: Delayed Incidence not known
  • Oral ulceration: Delayed Incidence not known
  • Gastritis: Delayed Incidence not known
  • Esophagitis: Delayed Incidence not known
  • Elevated hepatic enzymes: Delayed Incidence not known
  • Blurred vision: Early Incidence not known
  • Hyperuricemia: Delayed Incidence not known

Severe Adverse Reactions 

  • Bronchospasm: Rapid 0% to 1%
  • Anaphylactoid reactions: Rapid 0% to 1%
  • Fibrosing colonopathy: Delayed Incidence not known
  • GI obstruction: Delayed Incidence not known
  • Cholecystitis: Delayed Incidence not known

Contraindications

Although pancreatic enzyme replacement therapy does have any absolute contraindications per se, a careful analysis of the underlying risks is necessary for the following conditions.

Diabetes Mellitus 

Pancrelipase affects glycemic control. Hence patients diagnosed with diabetes mellitus or patient at risk for abnormal blood sugar levels should have strict glucose monitoring while taking pancrelipase.

Immunocompromised States

Pancrelipase is derived from the pancreatic tissue of swine. Although rigorous measures are taken to ensure no risk of transmission of viral infections to the patient, there is a theoretical risk from unknown viruses in the swine. Therefore, patients who are immunocompromised/immunodeficient are at an increased risk for contracting infections while on this medication.

Hyperuricemia and Renal Impairment

As this medication is porcine-derived, it contains certain nucleic acids that tend to increase blood uric acid levels. Patients with pre-existing hyperuricemia or gout as well as patients with decreased renal functions are to be closely monitored when on the drug.

Dysphagia

As mentioned earlier, patients with a tendency to retain the contents of the medications higher up in the gastrointestinal tract may develop mucosal irritation and mucositis. Care should be taken while administering the drug to patients with esophageal strictures and dysphagia.

Meconium Ileus, Intestinal Obstruction, Inflammatory Bowel Disease, and Surgery

Patients younger than 12 years of age, who have taken more than 6000 lipase units/kg per meal for more than 6 months, who have a history of meconium ileus, intestinal obstruction, inflammatory bowel disease, abdominal surgery have the highest risk for developing fibrosing colonopathy. It is a rare but serious complication of enzyme replacement and is characterized by GI obstruction, bloody diarrhea, abdominal pain, and poor weight gain.

Therefore, it has been recommended by the Cystic Fibrosis Foundation Consensus Conference Guidelines that the efficacy of lipase supplementation more than 2500 units/kg per meal be confirmed by a 3-day fecal-fat measure that indicated an increased fat absorption coefficient. The dose is then to be adjusted accordingly.

Pregnancy

Adequate human and animal reproduction studies have not been conducted. Therefore, its use in pregnancy should be limited to those patients with exocrine pancreatic insufficiency who have inadequate maternal weight gain. This may adversely affect fetal growth, and hence supplementation is justified.

Breastfeeding

All breastfeeding mothers should contact their healthcare provider before taking pancrelipase. Some proteins present in the product may be systemically absorbed along with the dietary protein. There is no data available about the absorption of these substances into breast milk; it is only recommended in cases when it is necessary to support the mother's nutritional status.

Porcine Protein Sensitivity

Anaphylactic reactions, hives, asthma, urticaria and, pruritus have all been reported in patients with prior hypersensitivity to porcine protein. Caution should be exercised with all these patients.

Monitoring

The maximum dosage of pancrelipase is as follows:

Adults

The recommendation is a maximum of 10,000 lipase units per kg per day orally (PO) or less than 4000 lipase units per gram of dietary fat per day.

Geriatric

The recommendation is a maximum of 10,000 lipase units per kg per day PO or less than 4000 lipase units per gram of dietary fat per day.

Adolescents

The recommendation is a maximum of 10,000 lipase units per kg per day PO or less than 4000 lipase units per gram of dietary fat per day.

But at no time should the maximum dosage exceed 2500 lipase units per kg per meal.

Infant Dosage

Infant dosages are product specific. But the maximum dosage is not to exceed 4000 lipase units per gram of ingested fat per day or 10,000 lipase units/kg per day.

Neonates

Neonatal dosages are product specific.

There are no dosage adjustments required for renal and hepatic impairment.

Drug Interactions That May Require Dosage Adjustments

  • Antacids: The efficacy of gastrointestinal enzyme replacement therapy is reduced in the presence of antacids. Calcium and magnesium cations exert their effect by forming poorly soluble calcium and magnesium soaps and precipitation of glycine-conjugated bile salts based on in-vitro studies.
  • Alpha-glucosidase inhibitors: The efficacy of alpha-glucosidase inhibitors is reduced by concurrent administration of gastrointestinal enzyme replacement. Ideally, both drugs should be given at different times. But this may not be possible, considering both drugs are to b administered around meal time.

Toxicity

Chronic, high-dose pancreatic enzyme replacement has been shown to cause colonic strictures and fibrosing colonopathy.[8] Fibrosing colonopathy is a condition in which there is a narrowing of the lumen of a long segment of the colon. This occurs due to submucosal widening due to deposition of mature collagen. Most commonly seen in children with cystic fibrosis as they require long-term high dose pancreatic enzyme replacement.

Enhancing Healthcare Team Outcomes

The administration of pancreatic enzyme replacement therapy requires the efficient functioning of an interprofessional team to ensure the best benefit to the patient. The team usually comprises a physician, nurse practitioner, pharmacist, nutritionist/dietician, physiotherapist, and nurses. The primary provider may additionally involve physicians from oncology, gastroenterology, surgery, pulmonology or pediatrics depending on the etiology of the enzyme insufficiency. The primary care provider is involved in the diagnosis of the insufficiency. He is then responsible for the management of the symptoms, deciding the supplementation requirements of the patients, monitoring progress and management of any side effects that might result thereof. Nurse practitioners are required to alternate with physicians to monitor patient progress with the medications. Pharmacists should provide patients and family with information on the drug, side effects, precautions and contraindications. They are also responsible for dose alterations as the case demands. Dieticians and nutritionists should assess the patient's nutritional status and determine the calorie requirement. They are also required to determine the need for vitamin supplements, growth hormone, and appetite stimulants. Physiotherapists are required to help with ambulation of patients with chronic illnesses like pancreatic cancer and chronic pancreatitis. They should also be on board when dealing with cases of cystic fibrosis. Nurses are an integral part of the team especially in the inpatient setting to ensure that all orders are executed. They are also an important link in communication between physicians and patients. No evidence is available for the effectiveness of a multi-disciplinary approach to pancreatic enzyme replacement therapy.

Various studies have shown the benefit of involving an interprofessional team for patients with cystic fibrosis.[9]


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Pancrelipase Therapy - Questions

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Which is true about the administration of pancrelipase to a patient with pancreatic insufficiency?



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A 32-year-old woman, well known to your practice, presents for a follow-up visit. She has a history of chronic pancreatitis and exocrine pancreatic insufficiency secondary to cystic fibrosis. Her gastrointestinal symptoms have been well controlled with pancrelipase therapy. She and her husband are beginning to plan for a family, and she wants to know if she can continue taking pancrelipase during pregnancy. What is the best response concerning the safety of pancrelipase during pregnancy?



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A 5-year-old female presents to the emergency department (ED) with severe abdominal pain and diarrhea. The patient has had about five to six loose stools per day for the last month. The patient's mother took her to a healthcare provider 2 months and was diagnosed with stunted growth. The child was started on oral pancreatic enzyme replacement at 20,000 lipase units/kg/day. She developed loose stools one month after starting pancrelipase. Lab work in the ED reveals a decrease in WBC counts. An ultrasound of the abdomen shows a possible mass in her right iliac fossa. She underwent genetic testing during infancy which revealed an abnormality. What is the mode of inheritance of this disorder, and what complication of pancrelipase use has the child developed?



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A 70-year-old male with myelodysplastic syndrome has been receiving regular blood transfusions for the past 8 years. He presents to your clinic with complaints of loose stools, decreased appetite, increased thirst, and frequent urination. He is found to have pancreatic insufficiency. You start him on pancrelipase and an oral hypoglycemic agent (OHA). Which OHA will you try to avoid in this setting?



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A 50-year-old female with a past medical history of chronic pancreatitis on pancreatic enzyme replacement therapy presented to the emergency department with new onset right upper quadrant abdominal pain. On examination, there was moderate hepatosplenomegaly. The patient's lab work showed a grossly elevated WBC count and 12% blast cells in the peripheral smear. She was started on a tyrosine-kinase inhibitor. Subsequently, her lab work showed a uric acid level of 20 mg/dL. The reason for this derangement is which of the following?



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Pancreatic lipase and acetylcholine are both serine proteases containing a catalytic triad. The catalytic triad comprises three amino acids. The catalytic triad in pancreatic lipase is which of the following?



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Pancrelipase Therapy - References

References

Giguere-Rich C,Mathew A,Reid E,Autore K,Guill MF, Use of an In-line Digestive Cartridge With Enteral Nutrition Improves the Weight Trajectory of 2 Children With Cystic Fibrosis Complicated by Another Medical Diagnosis. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2018 Apr     [PubMed]
Saito T,Nakai Y,Isayama H,Hirano K,Ishigaki K,Hakuta R,Takeda T,Saito K,Umefune G,Akiyama D,Watanabe T,Takagi K,Takahara N,Hamada T,Uchino R,Mizuno S,Mouri D,Yagioka H,Kogure H,Togawa O,Matsubara S,Ito Y,Yamamoto N,Tada M,Koike K, A Multicenter Open-Label Randomized Controlled Trial of Pancreatic Enzyme Replacement Therapy in Unresectable Pancreatic Cancer. Pancreas. 2018 Aug     [PubMed]
Stumpf JL,Kurian RM,Vuong J,Dang K,Kraft MD, Efficacy of a Creon delayed-release pancreatic enzyme protocol for clearing occluded enteral feeding tubes. The Annals of pharmacotherapy. 2014 Apr     [PubMed]
Min M,Patel B,Han S,Bocelli L,Kheder J,Vaze A,Wassef W, Exocrine Pancreatic Insufficiency and Malnutrition in Chronic Pancreatitis: Identification, Treatment, and Consequences. Pancreas. 2018 Sep     [PubMed]
Domínguez-Muñoz JE, Pancreatic enzyme replacement therapy: exocrine pancreatic insufficiency after gastrointestinal surgery. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2009 Dec     [PubMed]
Antonini F,Crippa S,Falconi M,Macarri G,Pezzilli R, Pancreatic enzyme replacement therapy after gastric resection: An update. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver. 2018 Jan     [PubMed]
Durie P,Baillargeon JD,Bouchard S,Donnellan F,Zepeda-Gomez S,Teshima C, Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel. Current medical research and opinion. 2018 Jan     [PubMed]
Dodge JA, Pancreatic enzymes and Fibrosing Colonopathy. Journal of cystic fibrosis : official journal of the European Cystic Fibrosis Society. 2015 Jan     [PubMed]
Collins S, Nutritional management of cystic fibrosis - an update for the 21st century. Paediatric respiratory reviews. 2018 Mar     [PubMed]

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