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

Evidence-based clinical practice guidelines for chronic pancreatitis 2021

BACKGROUND

Chronic pancreatitis (CP) is defined according to the recently proposed mechanistic definition as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress.

METHODS

The clinical practice guidelines for CP in Japan were revised in 2021 based on the 2019 Japanese clinical diagnostic criteria for CP, which incorporate the concept of a pathogenic fibro-inflammatory syndrome in the pancreas. In this third edition, clinical questions are reclassified into clinical questions, background questions, and future research questions.

RESULTS

Based on analysis of newly accumulated evidence, the strength of evidence and recommendations for each clinical question is described in terms of treatment selection, lifestyle guidance, pain control, treatment of exocrine and endocrine insufficiency, and treatment of complications. A flowchart outlining indications, treatment selection, and policies for cases in which treatment is ineffective is provided. For pain control, pharmacological treatment and the indications and timing for endoscopic and surgical treatment have been updated in the revised edition.

CONCLUSIONS

These updated guidelines provide clinicians with useful information to assist in the diagnosis and treatment of CP.

Rational Use of Pancreatic Enzymes for Pancreatic Insufficiency and Pancreatic Pain

We describe the rational use of enteric coated and unprotected replacement pancreatic enzymes for treatment of malabsorption due to pancreatic insufficiency and for pancreatic pain. Enteric coated formulations mix poorly with food allowing separation of enzymes and nutrients when emptying from the stomach. The site of dissolution of the enteric coating in the intestine is also unpredictable and enzymes may not be released until the distal intestine. Together, these barriers result in the lack of dose-response such that the strategy of increasing the dosage following a suboptimal effect is often ineffective. The ability to maintain the intragastric pH ≥4 with the combination of proton pump inhibitors and antacids suggests that it should be possible to reliably obtain a good response with uncoated enzymes. We also discuss the recognition, treatment and prevention of nutritional deficiencies associated with pancreatic insufficiency and recommend a test and treat strategy to identify and resolve nutritional deficits. Finally, we focus on mechanisms causing pain that may be amenable to therapy with pancreatic enzymes. Pain due to malabsorbed digestive contents can be prevented by successful therapy of malabsorption. Feedback inhibition of endogenous pancreatic secretion can prevent pain associated with pancreatic secretion but requires use of non-enteric coated formulations.

Evidence-based clinical practice guidelines for chronic pancreatitis 2015

Chronic pancreatitis is considered to be an irreversible progressive chronic inflammatory disease. The etiology and pathology of chronic pancreatitis are complex; therefore, it is important to correctly understand the stage and pathology and provide appropriate treatment accordingly. The newly revised Clinical Practice Guidelines of Chronic Pancreatitis 2015 consist of four chapters, i.e., diagnosis, staging, treatment, and prognosis, and includes a total of 65 clinical questions. These guidelines have aimed at providing certain directions and clinically practical contents for the management of chronic pancreatitis, preferentially adopting clinically useful articles. These revised guidelines also refer to early chronic pancreatitis based on the Criteria for the Diagnosis of Chronic Pancreatitis 2009. They include such items as health insurance coverage of high-titer lipase preparations and extracorporeal shock wave lithotripsy, new antidiabetic drugs, and the definition of and treatment approach to pancreatic pseudocyst. The accuracy of these guidelines has been improved by examining and adopting new evidence obtained after the publication of the first edition.

Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency in the 21st century

Restitution of normal fat absorption in exocrine pancreatic insufficiency remains an elusive goal. Although many patients achieve satisfactory clinical results with enzyme therapy, few experience normalization of fat absorption, and many, if not most, will require individualized therapy. Increasing the quantity of lipase administered rarely eliminates steatorrhea but increases the cost of therapy. Enteric coated enzyme microbead formulations tend to separate from nutrients in the stomach precluding coordinated emptying of enzymes and nutrients. Unprotected enzymes mix well and empty with nutrients but are inactivated at pH 4 or below. We describe approaches for improving the results of enzyme therapy including changing to, or adding, a different product, adding non-enteric coated enzymes, (e.g., giving unprotected enzymes at the start of the meal and acid-protected formulations later), use of antisecretory drugs and/or antacids, and changing the timing of enzyme administration. Because considerable lipid is emptied in the first postprandial hour, it is prudent to start therapy with enteric coated microbead prior to the meal so that some enzymes are available during that first hour. Patients with hyperacidity may benefit from adjuvant antisecretory therapy to reduce the duodenal acid load and possibly also sodium bicarbonate to prevent duodenal acidity. Comparative studies of clinical effectiveness of different formulations as well as the characteristics of dispersion, emptying, and dissolution of enteric-coated microspheres of different diameter and density are needed; many such studies have been completed but not yet made public. We discuss the history of pancreatic enzyme therapy and describe current use of modern preparations, approaches to overcoming unsatisfactory clinical responses, as well as studies needed to be able to provide reliably effective therapy.

Pancreatic enzymes for chronic pancreatitis

BACKGROUND

The efficacy of pancreatic enzymes in reducing pain and improving steatorrhoea is debatable and the evidence base for their utility needs to be determined.

OBJECTIVES

To evaluate the efficacy of pancreatic enzymes in patients with chronic pancreatitis. The specific objectives were to compare the following: 1) pancreatic enzyme versus placebo; 2) different pancreatic enzyme preparations and 3) different dosage schedules of the enzyme preparations. We evaluated the following outcomes: change in frequency of abdominal pain, duration of pain episodes, intensity of pain, weight loss, steatorrhoea, faecal fat and quality of life.

SEARCH STRATEGY

We devised a search strategy to detect all published and unpublished literature and the search included CENTRAL (The Cochrane Library 2009, issue 1), MEDLINE (1965 to February 2009) and EMBASE (1974 to Feburary 2009). We handsearched reference lists and published abstracts from conference proceedings to identify further relevant trials. The date of the last search was April 2009.

SELECTION CRITERIA

Randomised controlled trials with or without blinding. We included abstracts or unpublished data if sufficient information was available.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted and pooled the data pertinent to study outcomes. We combined continuous data using standardised mean difference (SMD) with 95% confidence interval (CI) and calculated the odds ratio (OR) for dichotomous data (95% CI).

MAIN RESULTS

Ten trials, involving 361 participants, satisfied the inclusion criteria. All the trials were randomised; two had a parallel design while the remainder had a cross-over design. Although some individual studies reported a beneficial effect of pancreatic enzyme over placebo in improving pain, incidence of steatorrhoea and analgesic consumption, the results of the studies could not be pooled for these outcomes. With the use of pancreatic enzymes, we observed a non-significant benefit for weight loss (kg) (SMD 0.06; 95% CI -0.23 to 0.34); a significant reduction in faecal fat (g/day) (SMD -1.03; 95% CI -1.60 to -0.46) and non-significant difference in subjects' Clinical Global Impression of Disease Symptom Scale (SMD -0.63; 95% CI -1.41 to 0.14). We found no significant benefit in reducing faecal fat with any particular schedule of enzyme preparation or type of enzyme.Another small study did not show any significant benefit of timing the administration of enzyme preparations in relation to meals on faecal fat.

AUTHORS' CONCLUSIONS

The role of pancreatic enzymes for abdominal pain, weight loss, steatorrhoea, analgesic use and quality of life in patients with chronic pancreatitis remains equivocal. Good quality, adequately powered studies are much warranted.

Efficacy of lower than standard doses of pancreatic enzyme supplementation therapy during acid inhibition in patients with pancreatic exocrine insufficiency

GOAL

To compare, during strong acid inhibition with omeprazole, the effect of 2 different doses of an enteric-coated pancreatic enzyme preparation on fecal fat excretion and abdominal symptoms in patients with exocrine insufficiency due to chronic pancreatitis (CP).

BACKGROUND

Treatment with pancreatic enzymes reduces fecal fat excretion in patients with CP but is rather unsuccessful due to irreversible lipase inactivation at pH below 4.

STUDY

Sixteen patients with CP (3 women, 13 men; age 53+/-3 y) participated in this randomized double blind 2-way cross over study. Fecal fat excretion and fat intake were measured and abdominal symptoms (visual analog scales) were scored during a 2 weeks control period, during omeprazole 60 mg+pancreatic enzymes 10,000 Fédération Internationale Pharmaceutique IU lipase tid (treatment A) for 2 weeks and during omeprazole 60 mg+pancreatic enzymes, 20,000 Fédération Internationale Pharmaceutique IU lipase tid (treatment B) for 2 weeks.

RESULTS

During acid inhibition with enzyme supplementation fecal fat excretion was significantly (P<0.01) reduced compared with control: 18+/-7 and 18+/-5 g/24 h versus 36+/-8 g/24 h for treatment A, B, and control, respectively. Abdominal symptom score and general well being improved significantly (P<0.05) during treatments A and B versus control. No differences in fat excretion or symptoms scores between treatments A and B were observed.

CONCLUSIONS

During strong acid inhibition, lower than recommended oral doses of pancreatic enzymes are therapeutically effective with respect to fat absorption and symptom reduction.

Acute pancreatitis and the role of histamine-2 receptor antagonists: a meta-analysis of randomized controlled trials of cimetidine

OBJECTIVES

Acute pancreatitis is a common disorder. Histamine type-2 receptor antagonists (H2RAs) are frequently used in patients with acute pancreatitis to reduce pancreatic juice secretion. However, most of the studies on this topic have involved only a few patients, demonstrating no beneficial effect but without harm. To clarify this matter, a meta-analysis was conducted to assess the efficacy of H2RAs.

METHODS

All randomized controlled trials written in English comparing the effects of H2RAs with those of placebo were retrieved. Clinical outcome data were extracted and the results pooled to yield odds ratios or weighted mean differences. Two investigators reviewed articles independently and reached a consensus.

RESULTS

A total of 285 patients from five studies were included. Cimetidine was the only H2RA used to treat acute pancreatitis. The pooled odds ratio of complications for H2RAs versus placebo was 1.64 (95% confidence interval [CI] 0.92 to 2.92). A weighted mean difference of duration of pain was 6.96 h (95% CI -2.50 to 16.43 h) in favour of placebo.

CONCLUSIONS

Cimetidine is not more effective than placebo in reducing acute pancreatitis-related complications and the duration of pain; rather, the use of cimetidine for acute pancreatitis could be associated with higher rates of complications and pain. Until the results of a large randomized trial show otherwise, H2RAs should not be used in the absence of specific clinical indications.

The exacerbation of pancreatic endocrine dysfunction by potent pancreatic exocrine supplements in patients with chronic pancreatitis

BACKGROUND

Chronic pancreatitis often culminates in maldigestion and diabetes. Clinical management is complex as the correction of maldigestion often disturbs diabetic control.

STUDY

In the following study, we examined the effects of a potent new commercial pancreatic enzyme on food absorption and blood glucose control. Enzymes were manufactured in enteric-coated mini-microsphere form (0.7--1.6 mm), designed to prevent gastric acid degradation and facilitate co-migration with food, and given in quantities calculated to cover normal digestion requirements (four capsules with meals, two with snacks; content/capsule: lipase 10,000 USP units, protease 37,500 units, amylase 33,200 units). Forty patients with chronic pancreatitis were screened during a run-in nonenzyme-supplemented phase; only those with stool fat excretion rates over 10 g/d (n = 29) were advanced to a 14-day parallel randomized placebo versus enzyme supplement group comparison.

RESULTS

Of these, 62% were diabetic (50% insulin-dependent) and 52% were malnourished (body mass index less than 20 kg/m(2) ). After enzyme supplementation, stool fat and nitrogen excretion decreased, whereas fat absorption increased from 54.0 +/- 9.7% to 80.8 +/- 3.8% per day (p = 0.002) and protein from 80.5 +/- 3.4% to 86.8 +/- 2.2% per day (p = 0.004). Changing treatment from active enzyme supplementation to placebo (and vice versa) resulted in major problems with glucose control; blood glucose levels became abnormal in 28 of 29 patients, one patient required hospitalization for symptomatic hypoglycemia (0.9 mmol/L) during placebo treatment, and one developed diabetic ketoacidosis after recommencing active enzyme supplementation.

CONCLUSIONS

In conclusion, high-dose pancreatin mini-microspheres improved, but did not normalize, fat absorption, possibly because of the residual influence of diabetes and malnutrition on absorptive function. In view of the brittle nature of blood glucose control in malnourished insulin-dependent patients, enzyme adjustment should be carefully supervised in-hospital.

Effects of high-lipase pancreatin on fecal fat, neutral sterol, bile acid, and short-chain fatty acid excretion in patients with pancreatic insufficiency resulting from chronic pancreatitis

CONCLUSIONS

Steatorrhea was almost completely stopped and malabsorption of neutral sterols and short-chain fatty acids was reduced by treatment of high-lipase pancreatin in Japanese patients with pancreatic insufficiency whose dietary fat consumption is low.

METHODS

Fifteen patients with chronic pancreatitis complicated by steatorrhea who consumed an average of 48 g of dietary fats a day were selected as subjects and given 3 g of high-lipase pancreatin (lipase, 379,800 USP U/g), at each meal (total daily dose is 9 g) for a mean duration of 28.5 d. Fecal output and fecal fat neutral sterol, bile acid, and short-chain fatty acid excretion were determined before and after the course of pancreatin therapy.

RESULTS

Pancreatin administration resulted in significant reductions (P < 0.01) in fecal output (from 243.2 to 149.1 g), excretion of fecal fat, (from 12.3 to 3.9 g), animal sterols (from 816.3 to 604.6 mg), and short-chain fatty acids (from 52.6 to 18.5 mM). In contrast, no marked changes were recorded in fecal excretion of beta-sitosterol (a plant sterol), bile acids, or the hydroxy fatty acid fraction. Fecal fat and short-chain fatty-acid excretion showed strong correlations with fecal output.

Phosphatidylcholine hydrolysis is required for pancreatic cholesterol esterase- and phospholipase A2-facilitated cholesterol uptake into intestinal Caco-2 cells

Pancreatic secretion is required for efficient cholesterol absorption by the intestine, but the factors responsible for this effect have not been clearly defined. To identify factors involved and to investigate their role in cholesterol uptake, we studied the effect of Viokase(R), a porcine pancreatic extract, on cholesterol uptake into human intestinal Caco-2 cells. Viokase is capable of facilitating cholesterol uptake into these cells such that the level of uptake is 5-fold higher in the presence of solubilized Viokase. This stimulation is time-dependent and is dependent on the presence of bile salt. However, bile salt-stimulated pancreatic cholesterol esterase, which has been proposed to mediate cholesterol uptake, is not fully responsible. The major cholesterol transport activity was purified and identified as pancreatic phospholipase A2. Anti-phospholipase A2 antibodies abolished virtually all of the phospholipase A2 and cholesterol transport activity of solubilized Viokase. We demonstrate that both phospholipase A2 and cholesterol esterase increase cholesterol uptake by hydrolyzing the phosphatidylcholine that is used to prepare the cholesterol-containing micelles. In the absence of cholesterol esterase or phospholipase A2, uptake of cholesterol from micelles containing phosphatidylcholine is not as efficient as uptake from micelles containing phospholipase A2-hydrolytic products. These results indicate that phospholipase A2 may mediate cholesterol absorption by altering the physical-chemical state of cholesterol within the intestine.

Carboxyl ester lipase (bile salt-stimulated lipase), colipase, lipase, and phospholipase A2 levels in pancreatic enzyme supplements

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.

Pancreatitis. Evaluation and treatment

Acute and chronic pancreatitis present challenging problems for the physician. In acute pancreatitis, initial efforts should be directed toward supporting the patient hemodynamically. Recognition and early treatment of complications such as shock, renal failure, respiratory failure, hypocalcemia, abscess, hemorrhage, or unremitting symptoms caused by an impacted stone in the common bile duct are necessary. The cause of the pancreatitis must be identified, possibly for acute therapy, but certainly to prevent recurrences and progression of disease. In chronic pancreatitis, insufficiencies of pancreatic function must be identified and consequent malabsorption and diabetes treated appropriately. The major challenge is the relief of chronic pain. It is hoped that this can be accomplished medically, but in carefully selected cases, specific types of surgery may be required.

Nutrition and gastrointestinal disease

Nutrition and intestinal function are intimately interrelated. The chief purpose of the gut is to digest and absorb nutrients in order to maintain life. Consequently, chronic gastrointestinal (GI) disease commonly results in malnutrition and increased morbidity and mortality. For example, studies have shown that 50-70% of adult patients with Crohn's disease were weight-depleted and 75% of adolescents growth-retarded. On the other hand, chronic malnutrition impairs digestive and absorptive function because food and nutrients are not only the major trophic factors to the gut but also provide the building blocks for digestive enzymes and absorptive cells. For example, recent studies of ours have shown that a weight loss of greater than 30% accompanying a variety of diseases was associated with a reduction in pancreatic enzyme secretion of over 80%, villus atrophy and impaired carbohydrate and fat absorption. Finally, specific nutrients can induce disease, for example, gluten-sensitive enteropathy, whilst dietary factors such as fibre, resistant starch, short-chain fatty acids, glutamine and fish-oils may prevent gastrointestinal diseases such as diverticulitis, diversion colitis, ulcerative colitis, colonic adenomatosis and colonic carcinoma. The role of dietary antigens in the aetiology of Crohn's disease is controversial, but controlled studies have suggested that elemental diets may be as effective as corticosteroids in inducing a remission in patients with acute Crohn's disease. In conclusion, nutrition has both a supportive and therapeutic role in the management of chronic gastrointestinal diseases. With the development of modern techniques of nutritional support, the morbidity and mortality associated with chronic GI disease can be reduced. On the other hand, dietary manipulation may be used to treat to prevent specific GI disorders such as coeliac disease, functional bowel disease, Crohn's disease and colonic neoplasia. The future development of nutria-pharmaceuticals is particularly attractive in view of their low cost and wide safety margins.

Effect of omeprazole on changes in gastric and upper small intestine pH levels in patients with chronic pancreatitis

Gastric and upper small intestine pH levels were measured continuously over 24 hours in patients with chronic pancreatitis, and values obtained before and after the administration of omeprazole were compared. Additionally, omeprazole was administered for 2 weeks and the fecal excretion of fat was compared before and after drug therapy. Postprandial gastric pH levels, initially 2.9 to 3.2, increased by 1.6 to 2.1 after treatment. Postprandial upper small intestine pH levels, initially 5.1 to 5.5, increased by 0.7 to 1.0. The lowest pH value of the upper small intestine was 2.2 to 2.4 postprandially; this was increased by > 1.0 after omeprazole, and the amplitude of pH variation was reduced. The cumulative proportions of intraintestinal pH strata of < or = 3, < or = 4, or < or = 5, and higher, initially being 16.4% to 17.1%, 27.4% to 31.7%, and 52.6% to 57.8%, respectively, were remarkably improved after drug treatment. Gastric pH and upper small intestine pH levels showed a positive correlation; an increase in gastric pH levels by 2 corresponded to an increase in small intestine pH levels by 1. After omeprazole administration, mean fecal excretion of fat was decreased to 4.1 +/- 2.6 g/d (range, 1.1 to 9.8 g/d) from 6.5 +/- 3.9 g/d (range, 1.6 to 13.5 g/d). Decreases in excretion of fat averaged 3.4 g/d (range, 2.2 to 4.5 g/d) in patients with steatorrhea. It was concluded that steatorrhea due to chronic pancreatitis can be improved to some extent by improving upper small intestine pH levels following the elevation of gastric pH levels after administration of omeprazole.

Comparative effects of adjuvant cimetidine and omeprazole during pancreatic enzyme replacement therapy

In a double-blind, randomized crossover study, the hypotheses were tested that more powerful inhibition of gastric acid secretion by adjuvant omeprazole further improves the efficacy of pancreatic enzyme replacement therapy compared to adjuvant cimetidine and that excluding the influence of pH-related factors, by virtually complete inhibition of gastric acid secretion with 60 mg omeprazole daily, does not lead to total elimination of steatorrhea. During both adjuvant cimetidine and omeprazole treatment, fecal fat excretion was significantly lower compared to pancreatin monotherapy (P < 0.01). Omeprazole showed a trend towards a more favorable decrease of fecal fat excretion compared to cimetidine but no statistically significant difference. Steatorrhea was almost never abolished, even during 60 mg omeprazole daily. Generally, pH-related factors are considered to explain an inadequate therapeutic response during pancreatic enzyme replacement therapy. However, this study indicates that in vivo other factors also play a significant role.

Fat-soluble vitamin concentration in chronic alcohol-induced pancreatitis. Relationship with steatorrhea

In order to study the fat-soluble vitamin concentration of patients with chronic alcohol-induced pancreatitis (CAIP) we measured vitamins A and E, total lipids, and retinol-binding protein (RBP) in the plasma of 44 patients with CAIP and 83 controls (44 healthy controls; 39 Crohn's disease patients). Mean plasma vitamin E and vitamin E/total lipid ratio were significantly lower in CAIP when compared with either control or Crohn's disease groups. A low vitamin E/total lipid ratio was found in 75% of CAIP patients (91% with steatorrhea) and a ratio less than 1.0 was virtually 100% predictive of steatorrhea. The mean plasma vitamin A level for the CAIP group was significantly lower (overall 16%, 38% with steatorrhea) than in controls. Patients with CAIP show subnormal plasma levels vitamin E more often as compared to vitamin A. Further, the plasma vitamin E/total lipids ratio may be a sensitive and practical means in the detection and follow-up of steatorrhea in these patients.

Biochemical tests in the diagnosis of chronic pancreatitis and in the evaluation of pancreatic insufficiency

Chronic pancreatitis (adults) and cystic fibrosis (children) are the most common diseases leading to exocrine pancreatic insufficiency that, when reduced to < 5% of normal function, is characterised by steatorrhoea. The pathogenesis of the former condition is outlined, and recent concepts are emphasized. Biochemical tests to detect pancreatic insufficiency and to identify pancreatic disease as the cause of steatorrhoea include: serum enzyme tests (lipase, amylase, trypsin); stool chymotrypsin; isotopic tests based upon the assimilation of [14C] lipids and starch or excretion of the isotope as breath CO2, as well as the dual-labelled Schilling test; oral function tests utilising substrates hydrolysed by pancreatic enzymes such as benzoyl tyrosyl-p-aminobenzoic acid and fluorescein dilaurate; and duodenal intubation studies following meal-induced or hormonal stimulation of the pancreas. The rationale for these tests and the cumulative clinical experience of their utility are reviewed. A recommended diagnostic strategy is briefly presented. The role of various biochemical procedures to evaluate the efficacy of pancreatic enzyme replacement therapy is also described.

Enzymes as agents for the treatment of disease

The replacement of genetically deficient enzymes in patients with inherited metabolic disorders by infusion of purified enzymes or by organ transplantation has had very limited success, although good results with bone marrow transplantation have been obtained in some patients with mucopolysaccharidosis, Gaucher disease and inherited immunodeficiency diseases. Genetic engineering of the patient's lymphocytes may ultimately render these approaches redundant, at least for some of these diseases. Treatment of chronic pancreatic insufficiency and of disaccharidase deficiency with oral enzymes can be very effective; therapy can be monitored in the latter by measuring the breath hydrogen excretion and in the former by a range of tests of which stool chymotrypsin assay is the most convenient. Treatment of acute myocardial infarction by intracoronary perfusion of thrombolytic enzymes can improve both cardiac function and long-term survival if given early enough. Successful reperfusion can be identified by changes in the kinetics of serum enzyme release and clearance, especially for the isoenzymes and isoforms of creatine kinase. In cancer chemotherapy, L-asparaginase has long been a useful adjunct in the treatment of acute lymphoblastic leukemia, but recent experience suggests a role in acute nonlymphoblastic leukemia as well.

Monitoring the effect of substitution therapy in patients with exocrine pancreatic insufficiency

Twenty-three outpatients with chronic pancreatitis and severe exocrine insufficiency were studied for the purpose of comparing the effect of Pancrease, Pankreon, and Pankreatin by estimation of duodenal enzyme activity, the faecal fat excretion, and the faecal 14C-triolein-3H-oleic acid test and, at the same time, to evaluate these tests when monitoring outpatients. The three preparations did not disclose any significant difference in treating steatorrhoea. Pankreatin increased the meal-stimulated duodenal enzyme activity (p less than 0.01) and caused reduction in the faecal fat excretion (p less than 0.05), whereas no change in these variables were observed with Pankreon or Pancrease. The faecal 14C-triolein-3H-oleic acid test showed significant improvement in the 14C-triolein digestion with all three preparations (p less than 0.01). The faecal 14C-triolein-3H-oleic acid test was the most reliable when monitoring outpatients.

Monitoring enzyme replacement treatment in exocrine pancreatic insufficiency using the cholesteryl octanoate breath test

The cholesteryl-14C-octanoate breath test was used to monitor the intraluminal enzymatic activity of pancreatin preparations in six patients with severe pancreatic insufficiency. Conventional enzyme replacement, with cimetidine as an adjunct, was compared to supplementation with enteric coated microspheres. In healthy control subjects, 14CO2 excretion rose rapidly and peaked at 90-120 minutes; mean (SD) cumulative recovery at four hours was 51 (8)%. In patients with pancreatic insufficiency on no treatment mean (SD) cumulative recovery was only 6 (4)%. After pancreatin, with previous administration of cimetidine, it increased to 27 (11)% with a time course resembling that in controls. With 2 mm enteric coated microspheres, 14CO2 excretion did not rise significantly before 120 minutes and cumulative recovery after four hours was 15 (11)%. In a control study, 2 mm radio-opaque microspheres did not empty from the stomach until two hours after ingestion. The results suggest that the cholesteryl octanoate breath test can be successfully used to monitor the intraluminal enzymatic activity after treatment with different forms of enzyme replacement in pancreatic insufficiency. In contrast to treatment with conventional pancreatin and cimetidine as an adjunct, 2 mm enteric coated microspheres did not show in vivo enzymatic activity until two hours after administration.