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Brown A, Hughes M, Tenner S, Banks PA. Does pancreatic enzyme supplementation reduce pain in patients with chronic pancreatitis: a meta-analysis. Am J Gastroenterol 1997; 92:2032-5. [PMID: 9362186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Pancreatic enzyme therapy is widely used in the treatment of pain in chronic pancreatitis. The aim of our study was to perform a meta-analysis to determine whether pancreatic enzyme supplementation significantly decreases abdominal pain in patients with chronic pancreatitis. METHODS From a MEDLINE search, we identified, evaluated, and subjected to a meta-analysis, six randomized, double-blind, placebo-controlled trials. Important features of data extraction included the method of subject inclusion, definition of disease, enzyme preparation, response to pancreatic enzyme therapy versus placebo, and modality for measuring response. RESULTS In the meta-analysis, the pooled estimate of the percentage of patients per study who preferred enzymes relative to placebo was 52% (95% confidence interval, 45-60%). A test of homogeneity indicated that there was no statistically significant heterogeneity across studies in the percentage of patients preferring enzymes. CONCLUSION Statistical analysis demonstrates no significant benefit of supplemental pancreatic enzyme therapy to relieve pain associated with chronic pancreatitis.
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Abstract
Fibrosing colonopathy, a recently described complication of patients with cystic fibrosis, manifests clinically approximately 7-12 months after starting high dose pancreatic enzyme treatment. Although the pathogenesis of fibrosing colonopathy is unknown, it is highly correlated with pancreatic enzyme dose. In this study, immune mediated factors which may be associated with fibrosing colonopathy were explored. Sera from 14 patients with cystic fibrosis and meconium ileus were collected at diagnosis and then longitudinally for four to five years after enzyme treatment. Sera were analysed for total IgG and antiporcine trypsin IgG using an ELISA assay. Before enzyme treatment, serum antiporcine trypsin IgG concentrations were negligible, at 2.9 (SD 0.3) micrograms/ml. Thirteen patients (93%) developed a significant antibody response to porcine trypsin after starting enzyme treatment, reaching a peak concentration of 69.4 (20.1) micrograms/ml 7-12 months after the introduction of enzymes. Since peak IgG concentrations coincided with published reports of time of onset of symptoms of fibrosing colonopathy, local injury by protease or by immune mediated mechanisms may be responsible for the pathological changes in this iatrogenic disease.
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Abstract
Cystic fibrosis is clearly a multisystem disease, which the potential for prominent gastrointestinal and hepatobiliary involvement. While the routine patient with pancreatic insufficiency may be easily managed with pancreatic enzyme and nutritional therapy, a large number of individuals with cystic fibrosis will present the clinician with gastrointestinal problems requiring additional thoughtful evaluation and treatment. Familiarity with the common gastrointestinal manifestations of cystic fibrosis and emerging therapies is necessary to provide the comprehensive care these patients deserve.
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Amarri S, Harding M, Coward WA, Evans TJ, Weaver LT. 13Carbon mixed triglyceride breath test and pancreatic enzyme supplementation in cystic fibrosis. Arch Dis Child 1997; 76:349-51. [PMID: 9166030 PMCID: PMC1717143 DOI: 10.1136/adc.76.4.349] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Children with cystic fibrosis have variable degrees of exocrine pancreatic insufficiency which, if untreated, is the main cause of fat malabsorption. The impact of pancreatic enzyme supplementation on fat digestion was measured in 41 children with cystic fibrosis, 11 healthy controls, and five children with mucosal diseases by a non-invasive test of intraluminal lipolysis using 13carbon (13C) labelled mixed triglyceride (1,3-distearyl, 2[13C] octanoyl glycerol). The children with cystic fibrosis without pancreatic supplements had a median (range) 13C cumulative percentage dose recovered over six hours (cPDR) of 3.1% (0-31.7), the controls 31.0% (21.8-41.1), and the subjects with mucosal disease 27.8% (19.7-32.5). In 23 subjects with cystic fibrosis the usual dose of pancreatic enzyme supplements increased the cPDR to a median of 23.9% (0-45.6), and twice the usual dose of enteric coated microspheres increased the cPDR to 31.1% (11.1-47.8). There was no significant difference between the median cPDR of normal controls and children with mucosal disease, but there was a highly significant difference between these groups and children with untreated cystic fibrosis. Thirteen children with cystic fibrosis had no 13C recovery in their breath without enzymes and 10 showed marked increases with regular enzymes. In eight children doubling the dose of enzymes caused no or minimal improvement. The mixed triglyceride breath test offers a simple, non-invasive way of assessing the need for pancreatic enzyme supplementation in children with cystic fibrosis and could be used to optimise treatment.
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Sternby B, Nilsson A. Carboxyl ester lipase (bile salt-stimulated lipase), colipase, lipase, and phospholipase A2 levels in pancreatic enzyme supplements. Scand J Gastroenterol 1997; 32:261-7. [PMID: 9085464 DOI: 10.3109/00365529709000204] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreatic lipolytic activity originates from lipase (LIP) and its cofactor colipase (COL), carboxyl ester lipase (CEL), and phospholipase A2 (PLA2). Yet there are few data on the levels of individual lipolytic enzymes in pancreatic enzyme supplements (PES). This study determines activity and immunoreactive mass in some commonly used PES and thus contributes to the understanding of the poor relationship between 'lipase dose' and clinical improvements. METHODS Recommended doses of each PES were incubated at 37 degrees C for 2 h in a 1-mM Tris-maleate buffer, pH 7.0, containing 150 mM NaCl and 1 mM CaCl2. Aliquots for determinations of enzyme activities and for immunochemical mass were taken every half hour. For comparison a standard dose was defined as 10,000 declared lipase units. RESULTS No simple parallelism between LIP, COL, CEL, and/or PLA2 activities was seen. The LIP contents ranged from 135% to 301% of the standard dose. None of the PES were short of COL (227%-504%). The variation in CEL was twentyfold, and in PLA2 sevenfold. Less variations were seen in the mass composition. There was considerable variation in activity to mass ratios (particularly for CEL), declared lipase units per recommended dose (6000-160,000), and cost (0.36-3.52 SEK). CONCLUSIONS PES differ considerably in their content of lipolytic enzymes. CEL activities were relatively low and COL and PLA2 activities high compared with normal duodenal content. The manufacturing procedure can be improved to increase the lipolytic activity in PES in a broader meaning. It seems to be most important to increase the amount of CEL. From these in vitro data we advocate a more careful decision in the choice of PES for each patient, depending on the total clinical picture. Money can be saved without disadvantage to the patient.
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Delhaye M, Meuris S, Gohimont AC, Buedts K, Cremer M. Comparative evaluation of a high lipase pancreatic enzyme preparation and a standard pancreatic supplement for treating exocrine pancreatic insufficiency in chronic pancreatitis. Eur J Gastroenterol Hepatol 1996; 8:699-703. [PMID: 8853261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of two enzyme-containing preparations, Pancrease HL (Cilag) containing 25,000 units of lipase per capsule and Creon (Triosol) with 8000 units of lipase per capsule, in patients with chronic pancreatitis and exocrine insufficiency. DESIGN The study is a monocentric open crossover prospective study including 25 patients entered from March 1993 to May 1994. PATIENTS Chronic pancreatitis was alcohol-related in 23 patients, previous surgery was performed in 9, 16 had diabetes and all had steatorrhoea (fat balance > 10g/24h). METHODS Patients were investigated during four periods of 2 weeks, each one corresponding to a new treatment regimen: Pancrease HL, 3 capsules/day or Creon, 9 capsules/day, with or without omeprazole 20 mg/day. Stools were collected on the last 3 days at the end of each period when the patients were on a standard diet with a fixed daily intake of 100 g fat/day. RESULTS Faecal fat, protein and energy excretion did not differ when both preparations were compared at roughly pharmaceutically equivalent doses. No significant improvement in fat and protein absorption was observed when omeprazole was taken with the pancreatic enzymes. However, omeprazole treatment was associated with a marked decrease in the fat-protein content ratio, suggesting an improvement in the fat digestive process but a decrease in the efficiency of protein digestion. Drug safety was comparable in the four groups of treatment. CONCLUSION Pancrease HL with high lipase activity provides effective pancreatic enzyme replacement therapy in patients with chronic pancreatitis at an appreciably lower number of capsules per day than with standard preparations.
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Takács T, Tiszai A, Lonovics J. [Studying the effect of enzyme replacement in chronic pancreatitis]. Orv Hetil 1996; 137:1033-6. [PMID: 8927326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Authors studied the effect of Neo-Panpur in chronic pancreatitis patients with moderate or severe exocrine pancreatic insufficiency. Patient's complaints, laboratory parameters and pancreatic function were also registered. Indications of pancreatic substitution therapy and the advantages of Neo-Panpur treatment are also discussed.
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Winklhofer-Roob BM, Tuchschmid PE, Molinari L, Shmerling DH. Response to a single oral dose of all-rac-alpha-tocopheryl acetate in patients with cystic fibrosis and in healthy individuals. Am J Clin Nutr 1996; 63:717-21. [PMID: 8615354 DOI: 10.1093/ajcn/63.5.717] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Biochemical vitamin E deficiency and low plasma lipids are frequent findings in patients with cystic fibrosis (CF). The response to a single oral dose of all-rac-alpha-tocopheryl acetate [100 IU (100 mg)/kg body wt] was studied over 24 h in 25 CF patients with exocrine pancreatic insufficiency and in 23 healthy individuals. Patients received pancreatic enzymes together with the vitamin E test dose. At baseline, plasma alpha-tocopherol concentrations correlated with cholesterol concentrations; both were lower in patients than in control subjects, as were erythrocyte alpha-tocopherol concentrations (all P < 0.0001). Plasma and erythrocyte alpha-tocopherol concentrations were significantly higher than baseline concentrations from 3 and 6 h onward, respectively, and peaked most frequently at 6 and 12 h, respectively, in both patients and control subjects. Maximum increases and areas under the concentration time curves for plasma alpha-tocopherol concentrations were smaller in patients than in control subjects (P < 0.0001). When ratios of plasma alpha-tocopherol to cholesterol (to correct for differences in cholesterol concentrations) or erythrocyte alpha-tocopherol concentrations were applied, patients were shown to respond as efficiently as control subjects. On the basis of these results, we recommend vitamin E supplements in doses high enough to achieve vitamin E status in CF patients well within the range of healthy individuals; these supplements should be given with appropriate amounts of pancreatic enzymes. However, for long-term supplementation much lower doses than those used in this test situation may be sufficient.
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Littlewood JM. Management of malabsorption in cystic fibrosis: influence of recent developments on clinical practice. Postgrad Med J 1996; 72 Suppl 2:S56-62; discussion S59-62. [PMID: 8869184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Caliari S, Benini L, Sembenini C, Gregori B, Carnielli V, Vantini I. Medium-chain triglyceride absorption in patients with pancreatic insufficiency. Scand J Gastroenterol 1996; 31:90-4. [PMID: 8927947 DOI: 10.3109/00365529609031633] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The role of medium-chain triglycerides (MCTs) in the management of patients with pancreatic insufficiency is controversial. The aim of the study was to evaluate the absorption of MCTs in the presence of pancreatic insufficiency and the effect of pancreatic extracts on MCT absorption so as to clarify whether the replacement of usual dietary fats with MCTs is cost-effective. METHODS Six patients with severe pancreatic steatorrhea were for 5 days fed a low-fat diet to which butter (long-chain triglycerides (LCTs)) or MCT oil was added, with and without pancreatic extracts, in a crossover design. RESULTS Fecal weight and nitrogen losses were the same during MCT and LCT intake. Steatorrhea was substantial during both periods but was significantly lower during MCT than LCT intake. Fecal weight and nitrogen and fat losses were reduced by pancreatic extracts in both diets. Steatorrhea was the same when MCTs and LCTs were consumed together with pancreatic extracts. CONCLUSIONS MCTs are absorbed better than LCTs in the presence of pancreatic insufficiency but require pancreatic extracts for optimal absorption. No advantage is to be expected from replacing usual dietary fats with MCTs if pancreatic supplements are used.
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Crenn C, Ezanno L, Tilly F. [Cystic fibrosis: nutritional strategy]. SOINS. PEDIATRIE, PUERICULTURE 1995:21-5. [PMID: 8715096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Bruno MJ, Haverkort EB, Tytgat GN, van Leeuwen DJ. Maldigestion associated with exocrine pancreatic insufficiency: implications of gastrointestinal physiology and properties of enzyme preparations for a cause-related and patient-tailored treatment. Am J Gastroenterol 1995; 90:1383-93. [PMID: 7661155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Clinical conditions in which secondary maldigestion associated with exocrine pancreatic insufficiency occur include chronic pancreatitis, cystic fibrosis, pancreatic cancer, partial or total gastrectomy, and pancreatic resection. Maldigestion can cause serious weight loss, nutritional deficiencies, and subjective complaints associated with steatorrhea. The various causes of exocrine pancreatic insufficiency may be associated with cause-related changes in gastrointestinal physiology, such as changes in gastrointestinal intraluminal pH, bile acid metabolism, gastric emptying, and intestinal motility. Therefore, to optimize the efficacy of treatment, the management of exocrine pancreatic insufficiency must be individually tailored to account for both the underlying cause and any associated disturbance in gastrointestinal physiology. In addition, the properties of the pancreatic enzyme preparations and adjuvant drugs need to be taken into consideration. This paper reviews the pathophysiological mechanisms of maldigestion in exocrine pancreatic insufficiency, discusses the efficacy of different therapy regimens, and gives guidelines for a cause-related and patient-tailored treatment with respect to both drug therapy and dietary counselling.
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Rodger HD, Murphy K, Drinan EM, Kennedy G. Apparent lack of response of salmon affected by pancreas disease to pancreatic enzyme replacement therapy. Vet Rec 1995; 136:489-91. [PMID: 7544043 DOI: 10.1136/vr.136.19.489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A trial was conducted to establish whether there would be any benefit in feeding mammalian pancreatic enzymes to farmed salmon clinically affected by pancreas disease. Pancreatic enzymes were incorporated at a rate of 4 kg/tonne of feed and fed at 0.6 to 0.9 per cent bodyweight/day for 41 days to one cage of salmon. The weights, lengths and condition factors were established for the fish before and after the feeding trial and compared with those for an adjacent cage of untreated fish. Histopathology and blood amylase and lipase activities were monitored weekly. No significant increases in weight or condition factor, and no reduction in mortalities were recorded. Histopathology confirmed the presence of pancreas disease throughout the trial and there were concurrent skeletal and cardiac myopathies. Blood amylase activities showed no significant change and were considered to be within normal ranges; blood lipase activity remained undetectable.
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Malesci A, Gaia E, Fioretta A, Bocchia P, Ciravegna G, Cantor P, Vantini I. No effect of long-term treatment with pancreatic extract on recurrent abdominal pain in patients with chronic pancreatitis. Scand J Gastroenterol 1995; 30:392-8. [PMID: 7610357 DOI: 10.3109/00365529509093296] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study was aimed to investigate the effect of long-term treatment with high-protease pancreatic extract on the recurrent abdominal pain of patients with chronic pancreatitis. METHODS Twenty-six patients with a firm diagnosis of chronic pancreatitis and a pattern of recurrent pain were recruited and randomly assigned to treatment with pancreatic extract (Pancrex-Duo capsules, each containing 34,375 USP units of protease in enteric-coated microspheres) or placebo, at a dose of four capsules four times daily, for 4 months. At the end of the first period patients were switched to the other medication for the next 4 months. Four patients did not complete the study because of unbearable recurring pain or inadequate compliance with treatment. The other 22 patients daily recorded the presence, intensity, and duration of pain and the consumption of analgesics, for 8 months. RESULTS No difference was found when intraindividual records during placebo and extract treatment periods were compared. Conversely, in the second 4 months of follow-up, regardless of the treatment given in the first period, there was a significant reduction in the cumulative pain score (median, 95; range, 0-1005, versus 134; 0-972; p < 0.05), in the number of days (8; 0-132, versus 13; 0-126; p < 0.02) and hours (54; 0-680, versus 80; 0-602; p < 0.05) of pain, and in the analgesic consumption score (0; 0-22, versus 12; 0-44; p = 0.02). CONCLUSIONS Chronic supplementation with pancreatic extract is not beneficial in the management of recurrent pain in patients with chronic pancreatitis.
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Billigmann P. [Enzyme therapy--an alternative in treatment of herpes zoster. A controlled study of 192 patients]. FORTSCHRITTE DER MEDIZIN 1995; 113:43-48. [PMID: 7713467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
PROBLEM Herpes Zoster requires an effective, inexpensive form of treatment not only because it impairs quality of life, but also on account of its relatively high incidence and the resulting costs incurred. Given the present situation in the health care sector, the high costs of treatment with the standard drug, acyclovir, often mean that herpes zoster patients do not receive medicinal therapy. AIM The aim of the present study was to establish whether the positive results of a prior investigation involving treatment with an enzyme combination preparation could be confirmed. METHOD Over a period of 14 days, two groups of 96 patients each were given acyclovir or an enzyme combination preparation. During the course of the study, the intensity (score) of segmental pain and various skin lesions were investigated. RESULTS In terms of the first end point, "segmental pain", the test groups showed no significant difference either on day 7 or on day 14. Although the second end point "segmental reddening" did reveal a significant difference (p = 0.015) in favor of the acyclovir group on day 14, no significant difference was found for any of the other examination endpoints. Nor did any of the other skin lesions evaluated differ significantly by the end of the study. CONCLUSIONS Overall, the enzyme combination preparation showed identical efficacy with acyclovir. The results of the prior study were thus confirmed. Further investigations on the immunomodulatory potency, dosage and effects on postherpetic herpes neuralgia are, however, still required.
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Ablin DS, Ziegler M. Ulcerative type of colitis associated with the use of high strength pancreatic enzyme supplements in cystic fibrosis. Pediatr Radiol 1995; 25:113-5; discussion 115-6. [PMID: 7596655 DOI: 10.1007/bf02010320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A 2 1/2-year-old girl with cystic fibrosis, who presented with hematochezia, developed an inflammatory ulcerative type of colitis with mild interstitial fibrosis and colonic narrowing while being treated with high strength pancreatic enzyme supplements. Findings of contrast enema, endoscopy, and colonic biopsy are described. The spectrum of colonic disease associated with the use of high strength pancreatic enzyme supplements in cystic fibrosis patients is discussed.
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Abstract
The medical records of patients subjected to distal pancreatectomy for chronic pancreatitis from 1982 to 1992 were reviewed to ascertain if pain relief could be predicted based on computed axial tomography (CAT) and endoscopic retrograde cholangiopancreatography (ERCP) findings. Of 10 patients who had severe pain preoperatively and disease limited to the body or tail of the pancreas, 9 had no pain or only mild pain postoperatively. Of 7 patients with severe pain preoperatively and diffuse disease or disease localized to the head of the pancreas, 6 required further hospitalization and resection or drainage procedures for severe, recurrent pain. We believe 50% to 60% of distal pancreatectomy procedures meet most criteria for the best operation for a select group of patients with chronic pancreatitis: those patients with severe pain, small ducts (< 5 mm), and whose disease is limited to the body or tail of the gland.
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