Compliance among adults with cystic fibrosis

Advances in therapy have largely contributed to the increased life expectancy of patients with cystic fibrosis. Unlike children, adults with cystic fibrosis must take responsibility for their own care. We administered a questionnaire to 23 adult patients (aged 18-39 years) with cystic fibrosis to (1) determine patients' degree of compliance with medications and chest physiotherapy; (2) collect information on their self-assessment of health motivation, disease severity, and benefits of treatment; and (3) identify barriers to receiving medical care. Patients reported better compliance with medications than with chest physiotherapy. Nine percent of the patients missed at least 25 percent of prescribed medication, whereas 47 percent missed at least 25 percent of prescribed physiotherapy. We observed a trend toward better compliance in patients who were highly worried about their health, who believed their illness to be serious, and who felt that their medications were very effective. Less than half of the study participants believed physiotherapy to be effective, and that adhering to a physiotherapy schedule was very difficult. Among adults with cystic fibrosis, compliance can be a serious problem that minimizes the benefits of good medical care. We suggest that emphasizing the severity of disease and usefulness of therapy may improve compliance and requires study.

[The use of conjunctival biomicroscopy and liquid-crystal thermography in diabetes mellitus in children and adolescents]

The importance of liquid-crystal thermography alongside with conjunctival biomicroscopy for the detection and verification of the nature of microcirculatory disorders and for the control of therapeutic efficacy was shown during the examination of 87 children and adolescents with diabetes mellitus. It has been proved that differentiated use of vasoactive drugs (Xauthnol Nicatinate, Andecalin, Pyrinolcarbamat) in patients with microcirculatory disorders exceeds 1.5-1.7-fold the results obtained in the control groups.

[Nigedase in the combined treatment of patients with chronic pancreatitis and enterocolitis]

The authors examined the efficacy of a new native agent of lipolytic action (nigedase, made in the USSR) used for the treatment of digestive disorders in 62 patients with chronic diseases of the pancreas and enterocolitis. Nigedase should be taken 1-2 tablets daily for 3-4 weeks. By its lipolytic action nigedase is more active than festal.

[Pancreatic kallikrein, a protector of small intestine damage in post-ischemic toxemia]

The morphofunctional state of the small intestine was studied on a tourniquet shock model. The development of postischemic toxemia is followed by disorders of microcirculation leading to irreversible changes in the small intestine. The processes are associated with an increase of the proteolytic activity of the intestinal contents. An oral administration of andecaline prevents ischemia of the intestine, contributes to the preservation of its mucosa.

Pancreatic enzyme replacement therapy. Importance of gastric acid secretion, H2-antagonists, and enteric coating

The relative efficacy of three commercial pancreatic enzyme supplements in improving fat absorption was studied using the [14C]triolein breath test in 12 patients with chronic pancreatitis. Two of the supplements were enteric coated. The one nonenteric coated product was studied twice: with and without ranitidine coadministration. Doses complied with the manufacturers recommendations. Baseline studies included pentagastrin-stimulated gastric acids, 72-hr fecal fat excretion, and [14C]triolein absorption while not on supplementation. Acid outputs were variable (BAO: 0.3-4.1 meq/hr; MAO: 3.5-34.6 meq/hr). Three patients had mild steatorrhea (i.e., less than 10 g/day) and the remaining severe fat malabsorption (56.9 +/- 41.5 g/day). Although fat absorption was significantly improved by all three supplements, the nonenteric coated preparation was most effective (P less than 0.001). However, laboratory analysis demonstrated that lipase content was four times greater, ie, 17,000 IU/4 tablets. Pretreatment with ranitidine failed to further improve the absorption in patients given nonenteric supplements but was effective in those found to have high or normal acid outputs (P less than 0.001). Our results suggest that the recommended dosage of enteric coated preparations is insufficient for adult patients with severe chronic pancreatitis. Secondly, the marked variability of acid secretion in such patients possibly accounts for the variability of results obtained by others on the usefulness of coadministration of antacids and H2 antagonists. Routine measurement of gastric acid secretion status may help optimize the choice and form of pancreatic enzyme supplementation.

Correction of malnutrition and maldigestion with enzyme supplementation in patients with surgical suppression of exocrine pancreatic function

We studied the occurrence and extent of malnutrition and maldigestion in 13 patients who underwent pancreatoduodenectomy (PD) and injection of Neoprene (polychloroprene) (NI) into the duct of Wirsung, which results in sclerosis of hte acinar pancreatic tissue, but spares the endocrine function. At discharge, patients under took an enzyme supplementation regimen with pancreatin (18, 00 United States Pharmacopoeia units of lipase per meal). Patients were rehospitalized 24.9 months after PD plus NI to undergo nutritional and metabolic evaluation (hospital control). Nutritional status was evaluated by measuring the serum albumin level, total iron binding capacity and total lymphocyte count. Digestive function was assessed by the D-xylose tolerance test and determination of fecal fat excretion. Patients were then discharged with pancrelipase, enteric-coated microspheres (ECM) supplementation (16,050 United States Pharmacopoeia units of lipase per meal). Malnutrition, defined as the occurrence of at least two abnormal nutritional parameters, was observed in six patients at hospital control. After six months on pancrelipase ECM, the nutritional status was re-evaluated in nine patients (three previously malnourished) who were all well nourished. The mean body weight was 84.7 per cent of usual body weight at discharge after PD plus NI and raised to 88.0 per cent at the hospital control (p less than 0.01) and to 93.7 per cent )p less than 0.05) after six months on pancrelipase ECM. At hospital control, results from the D-xylose test were normal in all patients, and steatorrhea dropped from 33.6 grams per day without enzyme supplementation to 15.3 grams per day with pancrelipase ECM (16,050 United States Pharmacopoeia units of lipase per meal). Steatorrhea was incompletely but satisfactorily corrected by pancrelipase ECM. On supplementation therapy with pancrelipase ECM, patients recover a good deal of the body weight and normalize the biochemical indices of malnutrition.

The management of enzymatic therapy in cystic fibrosis patients by an individualized approach

We evaluated nutritional status, pulmonary impairment, nutritional intake, and fat absorption in 73 cystic fibrosis (CF) patients to identify the primary factor(s) influencing growth. In general, the growth pattern in our patients was satisfactory since 60/73 were not underweight. When caloric intake is greater than or equal to 95% of RDA, wasting does not occur regardless of the degree of malabsorption, dietary fat content, or lung involvement. In the group of patients who consume less than the RDA, underweight is related to the severity of pulmonary disease; indeed, 11/13 underweight patients have a chest x-ray score over 15. Steatorrhea is well controlled in most patients; only 11 of 73 show a fat excretion greater than 25% of fat intake. The daily number of capsules of Pancrease varies from 4 to 57. The amount of Pancrease to be given was individualized to meet each patient's requirements using fat balance studies to determine the necessary daily Pancrease dose, then distributing the total dose in proportion to the fat content of each meal.

Duodenal instillation of pancreatin does not abolish steatorrhea in patients with pancreatic insufficiency

Many believe that intragastric deactivation of lipase accounts for the frequent failure of orally ingested pancreatic enzymes to normalize fat absorption in patients with pancreatic insufficiency. To test this hypothesis, we measured fat absorption from a large test meal in six patients with pancreatic insufficiency after we had instilled Viokase directly into the postcibal duodenum in two doses, one to deliver lipase at about 10% of normal secretory rates and the other at four times this rate. Direct duodenal instillation of neither the low nor the high dose of Viokase, nor the low dose of Viokase plus sodium bicarbonate, normalized fat absorption from the test meal; none of these duodenal instillations significantly improved fat absorption over that after the test meal plus orally ingested Viokase. Despite these various treatments, the patients excreted an average of 25.5 g of dietary fat as opposed to 2.1 g excreted by six normal subjects after the same meal. We conclude that more than just intragastric destruction of lipase underlies the frequent failure of orally ingested pancreatin to normalize fat absorption in pancreatic insufficiency.

Use of pancreatic Schilling test to determine efficiency of pancreatic enzyme delivery in pancreatic insufficiency

The pancreatic Schilling test (PST), a noninvasive, sensitive pancreatic function test, was studied to determine its ability to detect pancreatic proteolytic enzyme replacement in patients with pancreatic insufficiency. Seven subjects with well-documented pancreatic insufficiency and an abnormal PST consistent with pancreatic insufficiency were studied with three enzyme regimens: (1) Viokase (four tablets), (2) Pancrease (three capsules), and (3) Pancrease (10 capsules). The effect of cimetidine on the results of the PST with high-dose Pancrease was also determined in two subjects with pancreatic insufficiency and in two normal volunteers. The results of the investigation demonstrate that the PST is a sensitive noninvasive test for the presence of orally administered proteolytic enzymes in subjects with pancreatic insufficiency and in normals. Furthermore, the studies illustrate that the administration of enzymes in a form of enteric-coated microspheres does not enhance the delivery of proteolytic enzymes to the small intestine when compared to conventional high-dose enzyme replacement. Cimetidine appears to decrease the inactivation of the proteolytic enzymes in enteric-coated microspheres, suggesting that a low pH in the small intestine and stomach are responsible for the poor delivery of the enzymes into the small intestine.

Critical examination of therapeutic efficacy of a pH-sensitive enteric-coated pancreatic enzyme preparation in treatment of exocrine pancreatic insufficiency secondary to cystic fibrosis

In an attempt to critically examine the therapeutic efficacy of pH-sensitive enteric-coated pancreatic enzyme preparations in patients with pancreatic insufficiency due to cystic fibrosis, postprandial duodenal concentration and recovery of orally administered pancreatic enzymes, duodenal pH, and coefficient of fat absorption were determined in eight cases after ingestion of equivalent dosage of enteric-coated as well as conventional enzyme preparations. Ingestion of a pH-sensitive enteric-coated pancreatic enzyme preparation was accompanied with a significant (P less than 0.05) reduction in steatorrhea, as well as a lower mean concentration and recovery of lipase and trypsin activity in the postprandial duodenal samples. Furthermore, the intraluminal duodenal pH was noted to be below 4.0 during the postprandial period in all patients. These data suggest that in cystic fibrosis, the greater therapeutic efficacy of pH-sensitive enteric-coated preparations over conventional preparations may be related to the protection of pancreatic enzymes from the highly acidic milieu in the duodenum, allowing for possible bioavailability in the distal small intestine.

[Comparison of 2 pancreatic enzyme preparations in the treatment of digestive insufficiency in mucoviscidosis (cystic fibrosis)]

In an open trial 10 patients with cystic fibrosis were treated with two acid-protected pancreatic enzyme preparations formed as microtablets or pellets. The difference between Panzytrat 20,000 and Kreon is that with only 225 mg pancreatin, the former has twice the lipase activity of the latter. Therefore, the patients who had been taken Kreon were given only half the number of Panzytrat 20,000 capsules. There were no significant differences seen between the amounts of fecal fat nor in the fecal weight. In our study the fat absorption coefficient was somewhat too low with 67.4% for Kreon and 71.3% for Panzytrat 20,000 because of too low enzyme dosage, which was based only on an improvement of the clinical symptoms. Therefore, we would recommend a higher dose of 1000-1500 units of lipase/l g of dietary fat ingested. This requires the use of a preparation with high enzyme activity.

[Selenium and vitamin E in mucoviscidosis]

Selenium and vitamin E are two important components which protect membrane lipids from oxidative damage. Recently an abnormal fatty acid turnover in the membrane phospholipids was found in cystic fibrosis (CF). We studied vitamin E and selenium status in 26 CF children compared to a control group. we measured selenium concentration in plasma and erythrocytes using flameless atomic absorption. The measure of erythrocyte glutathione peroxidase activity allowed a functional assessment of selenium. Total plasma tocopherol concentrations (HPLC) were referred to total lipids. The vitamin E and selenium levels in not yet treated children (n = 6) were very low, with an important decrease in glutathione peroxydase activity. The antioxidative agents deficiency was mild in children with pancreatic enzyme replacement and vitamin E supplementation (n = 20). In the 2 groups, this deficiency was combined and may play a role in CF membrane abnormalities.

Total pancreatectomy for chronic pancreatitis

The operation of total pancreatectomy is performed rarely. Its role in the management of patients with chronic pancreatitis remains to be elucidated. We have reviewed our series of 29 total pancreatectomies for benign disease [14 women median age 39 years; 15 men median age 34 years]. Twelve underwent standard total pancreatectomy, in 17 duodenum preserving total pancreatectomy (DPTP) was performed. There was one death (mortality 3.4%). In no patient was the total pancreatectomy the first operative procedure. The patients were compared with age and sex matched diabetic control subjects selected on a best fit basis from the diabetic clinic database. The aetiology of the pancreatitis was idiopathic nine, pancreas divisum nine, alcohol eight and other causes three. The indication for surgery was pain 27, acute pancreatitis one and cholangitis with pancreatitis one. The complications of the procedures were mainly caused by infection [wound three, chest six and central line sepsis four] and in two there was a leak from the duodenum; no patient required re-operation. The postoperative stay [standard total, median 21 days (range 13-98) DPTP median 31 days (range 17-49)] has lengthened over the period due to greater attention to analgesic, diabetic and enzyme deficiency control before discharge. In standard total pancreatectomy there were five major hypoglycaemic episodes with only two in 17 DPTP patients. The per cent ideal body weight, the insulin requirement and the HbAl compared less well in standard total pancreatectomy group compared with controls than did DPTP. With both groups large doses of enzyme replacement were required, and this proved of importance in diabetic control. Our experience with total pancreatectomy suggests that pain will be improved in over 80% of patients and that the results of surgery will improve with prolonged follow up provided attention is given to analgesic abuse, enzyme deficiency and diabetes.

[Therapy of pancreatogenic steatorrhea. Comparison of 2 acid-protected enzyme preparations]

In an open, randomised cross-over trial nine patients with severe exocrine pancreatic insufficiency and considerable steatorrhea (greater than 25 g fecal fat excretion daily) received for five days, after a treatment-free period of three days, two new acid-protected enzyme preparations: Kreon, three times six capsules daily, pellets of 1-2 mm diameter; Panzytrat 20.000, three times three capsules daily, microtablets of 2 mm diameter. Both preparations significantly decreased fecal weight and fecal fat excretion. With equivalent lipase dosage there was no difference in effect between the two preparations.

Comparison of gastrointestinal pH in cystic fibrosis and healthy subjects

The primary objective of this study was to define the pH conditions under which supplemental pancreatic enzyme preparations must function in the upper gastrointestinal tract. The hypothesis was that normal or greater acid output in patients with cystic fibrosis (CF), combined with low pancreatic bicarbonate output, results in an acidic duodenal pH, compromising both dosage-form performance and enzyme activity. Gastrointestinal pH profiles were obtained in 10 CF and 10 healthy volunteers under fasting and postprandial conditions. A radiotelemetric monitoring method, the Heidelberg capsule, was used to continuously monitor pH. Postprandial duodenal pH was lower in CF than in healthy subjects, especially in the first postprandial hour (mean time greater than pH 6 was 5 min in CF, 11 min in healthy subjects, P less than 0.05). Based on the dissolution pH profiles of current enteric-coated pancreatic enzyme products, the duodenal postprandial pH in CF subjects may be too acidic to permit rapid dissolution of current enteric-coated dosage forms. However, the pH was above 4 more than 90% of the time on the average, suggesting that irreversible lipase inactivation in the duodenum is not likely to be a significant limitation to enzyme efficacy. Overall results suggest that slow dissolution of pH-sensitive coatings, rather than enzyme inactivation, may contribute to the failure of enteric-coated enzyme supplements to normalize fat absorption.