[Comparative clinical study of Neopanpur and Creon]

The aim of the study was to compare the clinical efficacy of Neopanpur (EGIS) and Creon (Kalichemie) in patients with chronic pancreatitis. Fifteen patients were examined for 2 x 10 days. A period: Neopanpur 3 x 2, B period: Creon 10,000 3 x 2. The type of the trial was: randomized, open, crossover study. The complaints of the patients (in score), the characters of the stool (daily weight, fat content, foamy, smell), amylum tolerance test (ATT), H2-breath test, lipjodol-test, Lundh-test and Schilling-test were determined before and during the treatment periods. Both enzyme preparations could effectively decrease the anamnestic complaints, the stool frequency and characteristics together with the laboratory results of pancreatic functions. There is no clinically significant difference between the clinical efficacy of Creon and Neopanpur. Both enzyme preparations can be applied in the treatment of maldigestion in patients with chronic pancreatic insufficiency.

Evaluation of different treatment methods in patients with psoriasis and content of kallikrein and kallikreinogen in blood plasma

158 patients with different forms of psoriasis were examined for the content of kallikrein and kallikreinogen in blood plasma and treated by different preparations including andecalin and dilminal-D. Changes in the kallikrein-kinin system may play a role in the development of psoriasis. The aim of this study was to investigate the relationship of changes in the kallikrein-kinin system induced by andecalin and dilminal-D and the clinical course of psoriasis. Determination of kallikrein and kallikreinogen content in blood plasma was made according to the methods of Paskhina and Krynskaya. Almost all psoriatic patients showed high kallikrein and kallikreinogen levels in blood plasma. We conclude that changes in the kallikrein-kinin system are involved in the pathogenesis of psoriasis. Andecalin and dilminal-D preparations resulted in a marked amelioration of psoriasis.

[Pancreatic extract therapy in exocrine pancreatic insufficiency]

The authors consider the different strategies in long term enzyme replacement therapy in relation to the complex mechanics at the basis of pancreas exocrine insufficiency. This condition occurs in chronic pancreatitis and is present in Cystic Fibrosis, the most common potentially lethal inherited disorder of Caucasians. Pancreatic exocrine insufficiency occurs in the vast majority of cystic fibrosis affected children and is now becoming a frequent pathology in adults for the better life expectancy and the recent acknowledgements in this disease. The principal aims of research in enzyme replacement therapy have been directed at the formulation of products with high enzyme concentration, to the prevention of gastric acid inactivation of enzymes and to the better mixing of the preparations with meals. The authors consider all the different enzyme preparations from pancreatin powder to the 1st. generation of enteric coated tablets and examine the advantages of administering H-2 receptor antagonists or antacids and the possibility of stimulating bicarbonate secretion as an adjunct to pancreatic enzyme replacement therapy. Significant benefits in pancreatic insufficiency therapy have derived from the introduction of enteric coated microspheres which ensure a consistent level of enzymes to reach the duodenum mixed with the meal and which are resistant to gastric acid inactivation as well.

Pharmacologic management of cystic fibrosis

Standard pharmacologic management of cystic fibrosis is discussed and the role of new agents in the treatment of this disease is explored. Cystic fibrosis is a recessive, fatal genetic disease involving multiple organ systems, in which patients develop pancreatic insufficiency, malabsorption, and repeated pulmonary infections. Pharmacotherapy to date has included broad-spectrum antimicrobials and aggressive nutritional management with microencapsulated pancreatic enzymes. Acute pulmonary exacerbations, caused by Pseudomonas aeruginosa, require combination i.v. antimicrobial therapy for 14 to 21 days. With the recent discovery of the genetic defect responsible for cystic fibrosis, as well as the cellular mechanism, new pharmacologic approaches are being explored to improve treatment. Aerosolized amiloride is being tested to modify the basic defect in the chloride channel. Dornase, a new mucolytic, is used to decrease sputum viscosity and increase mucociliary clearance. Leukoprotease inhibitors are currently being evaluated for decreasing the acute inflammatory reaction in the lung. Gene therapy has been promising, but its role in the management of cystic fibrosis is many years away. Drug therapy for cystic fibrosis has been primarily directed at treating infections with antibiotics and supplementing digestive enzymes and vitamins. New agents and gene therapy may substantially change the morbidity and mortality of this disease.

Pancreatic extracts are necessary for the absorption of elemental and polymeric enteral diets in severe pancreatic insufficiency

Tube feeding nutrition, either elemental or polymeric, is increasingly used in patients with digestive problems. Pancreatic insufficiency is a widely accepted indication for the use of an elemental formula, which requires less residual digestive capacity. To confirm this assumption, we have compared the absorption of elemental and polymeric diets and the effect of exogenous pancreatic enzymes in a patient on long-term total enteral feeding after total pancreatectomy. Malabsorption of both formulas was observed without enzyme supplementation. A marked improvement of fat and nitrogen absorption was obtained when pancreatic enzymes were added to both enteral diets. It is concluded that pancreatic enzymes should always be added to liquid diets in pancreatic insufficiency. No clear advantage is to be anticipated by the use of elemental as compared with polymeric diets.

Serum immunoglobulin G directed against porcine trypsin in the serum of cystic fibrosis children receiving porcine pancreatic enzyme supplements

Cystic fibrosis (CF) patients require pancreatic enzyme replacement therapy to correct pancreatic insufficiency. These enzymes are derived from porcine pancreas and are known to be antigenic. To determine the possible clinical consequences, a specific ELISA was developed to detect IgG antibody directed against porcine trypsin (PTAb) in the sera of CF patients. The assay was used to evaluate the occurrence of PTAb in a cross sectional study of 103 CF patients in relation to the introduction of porcine enzyme therapy, clinical status and genotype. Antibodies against porcine trypsin were detected in the sera of 63% of patients unrelated to the age of commencement or the duration of enzyme therapy. No differences were observed in the clinical status of CF patients who had developed PTAb (n = 65) and those who had no detectable PTAb (n = 38) as determined from: the current prescribed dose of porcine pancreatic enzyme capsules; Z scores for height and weight; and respiratory function tests. It is suggested that the PTAb commonly found in the sera of CF patients are of doubtful clinical significance but the prospect of PTAb contributing to immune complex disease should be examined further.

Exocrine pancreatic insufficiency

EPI in dogs represents a well-defined condition that can now be diagnosed simply by the analysis of a single serum sample for TLI. A low TLI concentration represents a highly sensitive and specific test for EPI and may also predict the development of disease before the onset of clinical signs. A lack of pancreatic enzymes results in interference with degradation of the major dietary constituents, and there are secondary changes in the small intestine including a decreased synthesis of enterocyte proteins; bacterial overgrowth in the proximal intestine (SIBO); and malabsorption of vitamins, including cobalamin. Management with uncoated pancreatic extract and a low-fat, high-quality protein diet fed in small, divided meals should be effective in most cases. In animals showing a poor response, additional treatment may be necessary with long-term oral antibiotic for SIBO and H2-receptor blockers before a meal to inhibit acid secretion and minimize degradation of pancreatic extract. Diagnosis of the relatively rare cases of EPI in cats is best achieved by analysis of fecal trypsin by the use of specific substrates until a TLI test becomes readily available, and management should follow similar principles to those established for dogs. The major question for the future is the underlying cause of pancreatic acinar atrophy in dogs, particularly the relative importance of genetic and environmental factors. This information may allow detection and elimination of a genetic abnormality by selective breeding or prophylactic treatment that would prevent the development of the disease.

Clinical pharmacology of commonly used drugs in GI practice. Part II

In Part I of this series of articles on clinical pharmacology of commonly used drugs in GI practice, drugs used in the GI laboratory, as adjuncts to endoscopic premedication, and as antibiotic prophylaxis for infective endocarditis and complications of endoscopy were presented. In Part II, drugs used in the management of peptic ulcer disease (antacids, H-2 receptor and proton pump antagonists), pancreatic enzymes, prokinetic agents, and drugs used with inflammatory bowel disease are described.

Chronic pancreatitis

Chronic pancreatitis is caused most often by chronic excessive alcohol consumption. The disease can be diagnosed by investigations that measure function or assess morphology of the pancreas, thereby permitting a tailored management approach. In many patients, abdominal pain and steatorrhea can be managed effectively by enzyme supplementation, provided such supplements are administered in appropriate formulations and doses. Definition and correction of mechanical problems are possible by modern endoscopic approaches, and surgery plays an important role in the management of local and regional complications of the disease.

New modalities in the treatment of exocrine pancreatic insufficiency in cystic fibrosis

Pancreatic insufficiency is the second most important pathophysiological expression of cystic fibrosis (CF) and occurs in the majority of patients. It leads to fat malabsorption and high energy losses in the stools and is one of the major causes of malnutrition often seen in CF. Although the development of enteric-coated enzyme preparations offers a dramatic improvement in therapy, it is still difficult to achieve complete correction of fat malabsorption. The cause for this treatment failure is the relative acidic environment in the duodenum induced by a decreased pancreatic bicarbonate output. To improve the efficacy of enteric-coated preparations the dissolution of these preparations in the duodenum must be optimised in order to achieve a high intraduodenal enzyme concentration. With the aim to increase intraduodenal pH, additional therapy with H2-antagonists and oral prostaglandins has been tested without unequivocal success. Omeprazole, a gastric acid inhibitor with more potency and duration of action compared to H2-antagonists, improves the efficacy of enteric-coated capsules of pancreatin dramatically. With a daily dose of 20 mg in addition to Pancrease (3 x 4 capsules) near normalization of faecal fat excretion will be reached in most CF patients with persistent steatorrhoea.

Dietary intake of healthy children with cystic fibrosis compared with normal control children

Because a low calorie intake may result in growth failure and malnutrition in patients with cystic fibrosis (CF), the dietary and energy intakes of 22 children with CF who had mild lung disease and excellent Shwachman scores were examined and compared with those of 23 normal control subjects similar in age (5 to 10 years), gender, and weight. The children with CF consumed significantly more calories than the control subjects. Calorie intake was 111 +/- 19.9% (mean +/- SD) of estimated requirements (World Health Organization recommendations) for the CF group and 97 +/- 18.7% for the control group (P = .014). Calories consumed per kilogram of body weight were 117% of World Health Organization (CF) vs 97% (control) (P = .009). Calorie intake compared to the 1989 Recommended Dietary Allowance was 106 +/- 20.6% for the CF group vs 93 +/- 19.1% for the control group. Fat consumed as a percent of total calories was similar: 33.5% (CF) vs 32.2% (control). All children with CF had pancreatic insufficiency and, on average, consumed a large number of pancreatic enzyme supplements, resulting in dietary fat absorption of 86 +/- 12%. It is concluded that these children with CF were able to maintain normal growth and energy stores on a diet that was relatively high in calories compared to control subjects and moderate in percent fat, along with an aggressive pancreatic enzyme supplement regimen.

Comparison between a standard pancreatic supplement and a high enzyme preparation in cystic fibrosis

This study compared the relative effectiveness of a standard pancreatic enzyme supplement ('Creon', Duphar) and a new preparation ('Pancrease HL', Cilag) containing about 3 times the lipase and more than 5 times the protease activity. Capsule dosage was adjusted to a ratio of approximately 3:1. Fat balances showed that absorption of fat did not change significantly on conversion to the new high-lipase product, and the coefficient of absorption of total energy was similarly maintained. The coefficient of protein absorption was significantly enhanced with the high enzyme preparation (P less than 0.01), which may explain the reported subjective improvement in stool odour. No adverse effects were recorded. Patient acceptability of the new compound was high; the great reduction in the number of capsules required at each meal was cited by all patients as the reason for their preference.

[The favorable effect of hydrolytic enzymes in the treatment of immunocytomas and plasmacytomas]

At present attention is focused on research of biomodulating influences on tumorous processes, in particular inhibition of metastatic spread of tumors. In the aetiopathogenesis an important part is played by immune complexes, interaction of cytokines. The authors tested the supporting effect of hydrolytic enzymes in plasmocytoma and immunocytoma. The enzymes were administered along with cytostatic preparations according to the MOCCA pattern. They recorded a more rapid onset and longer persistence of remissions, a marked decline of total proteins, paraproteins, beta-2-microglobulin. Complications associated with paraprotein (hyperviscosity syndrome, nephrotic syndrome, peripheral angiopathy) improved. A combination of chemotherapy and enzymatic treatment proved effective and suitable, in particular for patients with interferon intolerance.

A comparison of two pancreatin microsphere preparations in cystic fibrosis

OBJECTIVES

to compare the efficacy and tolerance of Creon and Pancrease in children and young adults with cystic fibrosis.

METHODS

a double blind, crossover study of two pH sensitive microsphere preparations of pancreatin (Creon, Pancrease), given in equivalent lipase dosage to 27 children with cystic fibrosis, was conducted.

RESULTS

at similar lipase activity no significant difference was found in the following: coefficient of fat absorption (CFA), coefficient of nitrogen absorption (CNA), weight gain, mean adequate daily intake for energy, and subjective symptoms. Three children who had a CFA less than 70% while receiving Pancrease all improved on Creon. No children had a CFA less than 70% while receiving Creon. A significant reduction in the number of capsules required daily to achieve similar control was possible when changing from Pancrease (mean 25/day) to Creon (mean 15/day). Seventy percent of patients preferred Creon and this was likely to be related to a perceived reduction in abdominal pain and stool frequency, and need for less capsules per day.

CONCLUSION

Creon and Pancrease are equally effective at doses providing equal lipase activity, however, the reduced number of capsules, fewer symptoms, and possible improvement of more severe steatorrhoea result in an increased patient preference for Creon.

[Therapy of chronic pancreatitis]

Therapy of chronic pancreatitis is dependent on the stage of the disease and its possible complications. A conservative therapy has to focus 1) on pain relief which implicates an understanding of the multiple causes of pain, 2) on therapy of the exocrine insufficiency by application of the appropriate pancreatic enzymes, dietary regimes, and substitution of fat soluble vitamins, and finally 3) therapy of endocrine insufficiency with insulin. The most important therapy is abstinence from alcohol. One special topic of this review is a discussion about the problem of "negative feedback regulation" of the exocrine pancreas with its question whether one can inhibit pancreatic secretion by application of pancreatic enzymes and, thus, reach a pain relieving effect. Various surgical procedures and possibilities of interventional endoscopy are briefly discussed.

Fate of orally ingested enzymes in pancreatic insufficiency: comparison of two pancreatic enzyme preparations

The effect on steatorrhoea of a pH-sensitive enteric-coated pancreatic preparation (Eurobiol 25,000) was compared with a conventional pancreatic enzyme preparation (Eurobiol) in six adult patients with exocrine pancreatic insufficiency. In addition, the fate of orally ingested pancreatic enzymes in the upper digestive tract was evaluated by measuring gastric and duodenal pH, amount of enzymes in the stomach, duodenal enzyme output, and fat absorption at the angle of Treitz for the 4 hours following a standard meal. When compared with placebo, Eurobiol and Eurobiol 25,000 reduced daily faecal fat excretion by 24% (not significant) and 43% (P less than 0.05), respectively. With the conventional preparation, enzyme output and fat absorption at the duodeno-jejunal flexure were significantly improved (P less than 0.05). Marked inter-individual differences in duodenal enzyme recovery (lipase 3% to 80%; chymotrypsin 26% to 100%) and, consequently, in the reduction of steatorrhoea (0% to 67%) were observed, with the gastric emptying rate emerging as a key determinant factor. With the enteric-coated preparation, enzyme output and fat absorption at the duodenojejunal flexure were not significantly improved. Discrepancy between the marked reduction of faecal fat excretion and the low duodenal enzyme recovery could indicate that enzyme delivery from microtablets occurs further down in the small bowel. Efficacy of enteric-coated preparations could be enhanced by adding unprotected enzymes, especially in patients with rapid gastric emptying.

[Prolipase in the treatment of dyspepsia in chronic liver diseases]

In 12 patients with chronic liver disease without detectable pancreatic insufficiency the authors tested in clinical trials the pancreatic enzyme preparation Prolipase (Cilag AG, Switzerland) in an attempt to influence the marked dyspeptic complaints of patients. They administered three times per day two capsules before meals for a period of three weeks. Half the patients evaluated the therapeutic effect as excellent, one quarter as very good, only one quarter did not observe a marked favourable effect on dyspepsia. Treatment was well tolerated and no undesirable side-effects were observed. Prolipase can thus be used in dyspepsias associated with chronic hepatic lesions.

[The dynamics of the healing of an infected fracture of mandibular bone exposed to andekalin and kontrikal]

Infected mandibular fracture was simulated in rats. 10 percent calcium chloride solution (control) or andecalin (10 U/Kg) and contrykal (2.5000 U/kg) were administered to fracture site by vacuum electrophoresis. Histologic examination has revealed that andecalin activated the exudative phase of inflammation and decelerated the proliferative processes. A contrary effect was induced by contrykal: rapidly decreasing exudation, activation of osteoclastic resorption of necrotic bone and of osteogenesis processes.