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Berry AJ, Bilbo A. Exocrine pancreatic insufficiency and pancreatic exocrine replacement therapy in clinical practice. Nutr Clin Pract 2024; 39 Suppl 1:S78-S88. [PMID: 38429965 DOI: 10.1002/ncp.11124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 03/03/2024] Open
Abstract
Exocrine pancreatic insufficiency (EPI) is a complex condition that disrupts normal digestion and absorption. Patients with EPI may suffer from mild to debilitating malabsorption with a constellation of symptoms that can have a significant effect on quality of life and nutrition status. Pancreatic enzyme replacement therapy (PERT) is effective and safe to treat EPI and is the standard of care for this condition. A wide variety and various forms of these products exist, as well as numerous guidelines and recommendations. Obtaining PERT for patients can oftentimes be cost prohibitive. Determining the presence and extent of EPI can be challenging and patient specific, making it difficult for practitioners. This narrative review will explore these issues, as well as several disease states potentially affected by EPI, and review current management strategies.
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Affiliation(s)
- Amy J Berry
- Department of Clinical Nutrition, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Amy Bilbo
- Department of Clinical Nutrition, Medical University of South Carolina, Charleston, South Carolina, USA
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Rosenberg J, Reddy MN, Seelam P, Li O, Twal J, Pack J. A Retrospective Real-World Evidence Evaluation of the Characteristics of Exocrine Pancreatic Insufficiency in Patients With Chronic Pancreatitis and Type 2 Diabetes Treated With Pancrelipase in the United States. Pancreas 2022; 51:1308-1314. [PMID: 37099771 PMCID: PMC10184798 DOI: 10.1097/mpa.0000000000002203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
OBJECTIVES This retrospective real-world data analysis assessed clinical/health care professional characteristics of gastrointestinal symptom profiles in pancrelipase-treated patients with exocrine pancreatic insufficiency symptoms and chronic pancreatitis (CP) or type 2 diabetes (T2D). METHODS Data were from the Decision Resources Group Real-World Evidence Data Repository US database. Patients 18 years and older receiving pancrelipase (Zenpep) between index dates August 2015 and June 2020 were included. Gastrointestinal symptoms were assessed 6, 12, and 18 months post-index versus baseline. RESULTS A total of 10,656 pancrelipase-treated patients with CP (n = 3215) or T2D (n = 7441) were identified. Significant/sustained reductions in gastrointestinal symptoms were observed in both cohorts after pancrelipase treatment (P < 0.001) versus baseline. Significantly fewer patients with CP compliant with treatment for more than 270 days (n = 1553) reported abdominal pain (P < 0.001) and nausea/vomiting (P < 0.05) versus those compliant for less than 90 days (n = 1115). Significantly fewer patients with T2D compliant with treatment for more than 270 days (n = 2964) reported abdominal pain (P < 0.001) and diarrhea/steatorrhea (P < 0.05) versus those compliant for less than 90 days (n = 2959). CONCLUSIONS Pancrelipase reduced exocrine pancreatic insufficiency symptoms in patients with CP or T2D, with greater treatment compliance associated with improved gastrointestinal symptom profiles.
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Affiliation(s)
- Jonathan Rosenberg
- From the Department of Gastroenterology, Illinois Gastroenterology Group, GI Alliance, Gurnee, IL
| | | | | | - Olivia Li
- RWE Analytics, Clarivate Analytics, Toronto, Canada
| | - Janine Twal
- Medical Science Liaison, Aimmune Therapeutics, a Nestlé Health Science company, Bridgewater Township, NJ
| | - Jennifer Pack
- Medical Science Liaison, Aimmune Therapeutics, a Nestlé Health Science company, Bridgewater Township, NJ
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Ferdek PE, Krzysztofik D, Stopa KB, Kusiak AA, Paw M, Wnuk D, Jakubowska MA. When healing turns into killing ‐ the pathophysiology of pancreatic and hepatic fibrosis. J Physiol 2022; 600:2579-2612. [DOI: 10.1113/jp281135] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/12/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Pawel E. Ferdek
- Department of Cell Biology Faculty of Biochemistry Biophysics and Biotechnology Jagiellonian University Krakow Poland
| | - Daria Krzysztofik
- Malopolska Centre of Biotechnology Jagiellonian University Krakow Poland
| | - Kinga B. Stopa
- Malopolska Centre of Biotechnology Jagiellonian University Krakow Poland
| | - Agnieszka A. Kusiak
- Department of Cell Biology Faculty of Biochemistry Biophysics and Biotechnology Jagiellonian University Krakow Poland
| | - Milena Paw
- Department of Cell Biology Faculty of Biochemistry Biophysics and Biotechnology Jagiellonian University Krakow Poland
| | - Dawid Wnuk
- Department of Cell Biology Faculty of Biochemistry Biophysics and Biotechnology Jagiellonian University Krakow Poland
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Carnie LE, Farrell K, Barratt N, Abraham M, Gillespie L, Satyadas T, McNamara MG, Hubner RA, Geraghty J, Bibby N, Valle JW, Lamarca A. Pancreatic Enzyme Replacement Therapy for Patients Diagnosed With Pancreaticobiliary Cancer: Validation of an Algorithm for Dose Escalation and Management. Pancreas 2021; 50:1254-1259. [PMID: 34860808 DOI: 10.1097/mpa.0000000000001906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE An algorithm was designed aiming to provide consistency of pancreatic enzyme replacement therapy (PERT) dosing/titration across healthcare professionals in pancreaticobiliary cancers (PBCs). This prospective observational study aimed to validate this algorithm. METHODS Consecutive patients with inoperable or postoperative PBC with pancreatic exocrine insufficiency (PEI) symptoms, not taking PERT, or taking below the algorithm "starting dose," were eligible. A dietitian or clinical nurse specialist reviewed patients for up to 3 weeks, titrating PERT as per the algorithm. Feasibility of algorithm deliverability was assessed by the percentage of patients with successful completion (primary objective). RESULTS Twenty-five patients were eligible (N = 25): at baseline, 22 took PERT (100% on suboptimal doses, 54.5% taking incorrectly) and 3 initiated PERT because of PEI symptoms. Algorithm completion (20 of 25, 80%) confirming deliverability by dietitians (11 of 12, 92%) and clinical nurse specialists (9 of 13, 69%). Symptom resolution occurred in 8 of 19 (42%), 3 of 7 (43%), and 1 of 3 (33%) patients at first, second, and third reviews, respectively; advice compliance was between 63% and 86%. CONCLUSIONS This algorithm provides a structured method to titrate PERT. At diagnosis, all patients with PBC should be assessed for PEI and adequate PERT initiated. Regular reviews are required for timely symptom resolution and adequate escalation, facilitating differential diagnosis if refractory symptoms exist.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Neil Bibby
- Dietetics, Manchester Royal Infirmary, Manchester, United Kingdom
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Maev IV, Kucheryavyy YA, Andreev DN. Exocrine pancreas insufficiency: clinical significance and approaches to correction from evidence medicine. TERAPEVT ARKH 2021; 93:509-515. [DOI: 10.26442/00403660.2021.04.200800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
Exocrine pancreatic insufficiency (EPI) is a common complication of both benign and malignant diseases of the pancreas, as well as a consequence of radical surgical operations on the pancreas and a whole range of other variable extra-pancreatic causes. In clinical practice in the adult population, most cases of EPI are associated with chronic pancreatitis, while in the pediatric population with cystic fibrosis. The regression of the production of digestive enzymes in EPI mediates the development of the syndrome of maldigestion and malabsorption, leading to the progressive development of malnutrition, the importance of which is often underestimated by practitioners. At the same time, the development of nutritional deficiency is not just a complication of EPI, but also has an important effect on the course of the underlying causative disease, worsening the prognosis and quality of life of the patient, and is also a proven risk factor for osteoporosis and sarcopenia. To date, compensation for the absolute deficiency of pancreatic enzymes using enzyme replacement therapy is the only possible way to correct the EPI and prevent nutritional deficiency.
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Nakagawa Y, Kato H, Maeda K, Noguchi D, Gyoten K, Hayasaki A, Iizawa Y, Fujii T, Tanemura A, Murata Y, Kuriyama N, Kishiwada M, Sakurai H, Isaji S, Mizuno S. Proximal subtotal pancreatectomy as an alternative to total pancreatectomy for malnourished patients. Surg Today 2021; 51:1619-1629. [PMID: 33825950 DOI: 10.1007/s00595-021-02269-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/31/2021] [Indexed: 01/29/2023]
Abstract
PURPOSE To investigate whether proximal subtotal pancreatectomy (PSTP) is superior to total pancreatectomy (TP) for preserving postoperative endocrine function, and to identify the pre-operative risk factors influencing prognosis after TP and PSTP. METHODS The subjects of this retrospective study were patients who underwent TP (n = 15) or PSTP (n = 16) between 2008 and 2018 in our hospital. First, we compared the incidence of hypoglycemia within 30 days after surgery and the total daily amount of insulin needed in the 30 days after TP vs. PSTP. Then, we compared the prognoses between the groups. RESULTS The incidence of hypoglycemia in the 30 days after surgery was significantly lower in the PSTP group than in the TP group (n = 0 vs. n = 5; p < 0.001). The total amount of daily insulin given was also significantly lower after PSTP than after TP: (0 units vs. 18 units, p = 0.001). Lower lymphocyte counts (p = 0.014), lower cholinesterase (p = 0.021), and lower prognostic nutrition index (p = 0.021) were identified as significant risk factors for hypoglycemia in the TP group. Low cholinesterase (p = 0.015) and a low prognostic nutrition index (p = 0.048) were significantly associated with an unfavorable prognosis in the TP group, but not in the PSTP group. CONCLUSIONS PSTP may be a feasible alternative to TP to preserve endocrine function, especially for malnourished patients.
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Affiliation(s)
- Yuki Nakagawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan.
| | - Koki Maeda
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Daisuke Noguchi
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
| | - Shuji Isaji
- Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan
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Fong ZV, Sekigami Y, Qadan M, Fernandez-Del Castillo C, Warshaw AL, Lillemoe KD, Ferrone CR. Assessment of the Long-Term Impact of Pancreatoduodenectomy on Health-Related Quality of Life Using the EORTC QLQ-PAN26 Module. Ann Surg Oncol 2021; 28:4216-4224. [PMID: 33774773 DOI: 10.1245/s10434-021-09853-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/30/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Long-term pancreatoduodenectomy (PD) survivors have previously reported favorable quality of life (QoL). However, there has been a paucity of studies utilizing pancreas-specific modules for QoL assessment, which may uncover disability that general modules cannot detect. METHODS The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-PAN26 questionnaires were administered to PD survivors who were at least 5 years out of their operations for neoplasms (1998-2011, study cohort) and compared their scores with published preoperative scores of patients with pancreatic cancer (control cohort). The clinical relevance (CR) of differences was scored as small (5-10), moderate (10-20), or large (> 20) based on validated interpretation of clinically important differences. RESULTS Of 1266 patients who underwent PD, there were 305 survivors with valid contact information, of whom 248 responded to the questionnaire (response rate 81.3%) and made up the study cohort. The median follow-up was 9.1 years (range 5.1-21.2 years). When compared with the control cohort, patients in the study cohort reported higher pancreatic pain (41.7 ± 17.6 vs. 18.1 ± 20.5, p < 0.001, CR large), sexuality dissatisfaction (63.0 ± 37.5 vs. 35.1 ± 34.3, p < 0.001, CR large), altered bowel habits (37.6 ± 30.6 vs. 20.0 ± 24.5, p < 0.001, CR moderate), and digestive symptoms (26.3 ± 29.5 vs. 18.7 ± 27.8, p = 0.002, CR small) scores. There was a higher prevalence of bloating, indigestion, and flatulence, but lower prevalence of future health worry (71.7% vs. 89.6%, p < 0.001) and limitation in planning activities (30.1% vs. 48.3%, p < 0.001) at 5 years. CONCLUSION While post-PD patients had better long-term global QoL than healthy controls, a more granular, pancreas-specific questionnaire uncovered digestive abnormalities and sexuality dissatisfaction. These data can better inform clinical decision making and provide potential areas for improvement and patient support.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Yurie Sekigami
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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Kim H, Yoon YS, Han Y, Kwon W, Kim SW, Han HS, Yoon DS, Park JS, Park SJ, Han SS, Lee SE, Choi SH, Han IW, Kim E, Jang JY. Effects of Pancreatic Enzyme Replacement Therapy on Body Weight and Nutritional Assessments After Pancreatoduodenectomy in a Randomized Trial. Clin Gastroenterol Hepatol 2020; 18:926-934.e4. [PMID: 31520730 DOI: 10.1016/j.cgh.2019.08.061] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/18/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We studied the effects of pancreatic enzyme replacement therapy (PERT) on body weight, nutritional status, and quality of life (QoL) in patients with pancreatic exocrine insufficiency after pancreatoduodenectomy. METHODS We performed a randomized, double-blind trial of 304 patients who underwent pancreatoduodenectomy at 7 tertiary referral hospitals in South Korea. Patients with fecal levels of elastase of 200 μg/g or less, before and after surgery, were assigned randomly to groups that received PERT (a single capsule of 40,000 IU pancreatin, Norzyme (40,000 IU, Pankreatan; Nordmark Arzneimittel GmbH & Co, Uetersen, Germany), 3 times each day during meals for 3 months; n = 151) or placebo (n = 153). Protocol completion was defined as taking more than two thirds of the total dose without taking other digestive enzymes; the protocol was completed by 71 patients in the PERT group and 93 patients in the placebo group. Patients underwent a physical examination, oral glucose tolerance tests, and blood tests at baseline and at month 3 of the study period. The primary end point was change in body weight. Secondary end points were changes in bowel habits, nutritional parameters, and QoL. RESULTS In the per-protocol analysis, 3 months after the study began, patients in the PERT group gained a mean of 1.09 kg in weight and patients in the placebo group lost a mean of 2.28 kg (difference between groups, 3.37 kg; P < .001). However, no difference in body weight was observed between groups in the intent-to-treat analysis. Three months after the study began, the mean serum levels of prealbumin increased by 10.9 mg/dL in the PERT group and increased by 7.8 mg/dL in the placebo group (P = .002). Poor compliance to PERT was a significant risk factor for weight loss (P < .001). There was no significant difference in QoL scores between groups. CONCLUSIONS In the intent-to-treat analysis of data from a randomized trial, we found no significant effect of PERT on mean body weights of patients with pancreatic exocrine insufficiency after pancreatoduodenectomy. However, with active education and monitoring, PERT could increase body weight and nutritional parameters. ClinicalTrials.gov no: NCT02127021.
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Affiliation(s)
- Hongbeom Kim
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea; Department of Surgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Youngmin Han
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea; Center for Liver and Pancreatobilary Cancer, National Cancer Center, Goyang, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Dong-Sup Yoon
- Department of Surgery, Gangnam Severance Hospital, Seoul, Korea
| | - Joon Seong Park
- Department of Surgery, Gangnam Severance Hospital, Seoul, Korea
| | - Sang-Jae Park
- Center for Liver and Pancreatobilary Cancer, National Cancer Center, Goyang, Korea
| | - Sung-Sik Han
- Center for Liver and Pancreatobilary Cancer, National Cancer Center, Goyang, Korea
| | - Seung Eun Lee
- Department of Surgery, Chung-Ang University Hospital, Seoul, Korea
| | - Seong Ho Choi
- Department of Surgery, Samsung Medical Center, Seoul, Korea
| | - In Woong Han
- Department of Surgery, Dongguk University Ilsan Hospital, Goyang, Korea; Department of Surgery, Samsung Medical Center, Seoul, Korea
| | - Eunjung Kim
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea; Department of Nursing, Graduate School, Kyung Hee University, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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Bideeva TV, Maev IV, Kucheryavyy YA, Andreev DN, Shah YS, Lobanova EG, Zaborovskiy AV, Levchenko AI. [The effectiveness of pancreatic enzyme replacement therapy using microencapsulated pancreatin preparations in the correction of nutritional status in patients with chronic pancreatitis: a prospective observational study]. TERAPEVT ARKH 2020; 92:30-35. [PMID: 32598660 DOI: 10.26442/00403660.2020.01.000488] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
AIM The goal is to evaluate the effectiveness of pancreatic enzyme replacement therapy (PERT) using microencapsulated pancreatin preparations for the correction of nutritional status in patients with chronic pancreatitis (CP) and associated exocrine pancreatic insufficiency (EPI). MATERIALS AND METHODS The study included 58 patients with CP who were divided into two groups depending on the results of a laboratory assessment of indicators of nutritional status: group I (n=30) consisted of patients with CP and signs of EPI (according to low elastase test values) without deviations in nutritional status; Group II (n=28) consisted of patients with CP with a EPI and an abnormal nutritional status. In both groups, patients during the entire observation period (8-12 months) received PERT using microencapsulated pancreatin preparations at a dose adjusted for the severity of permanent residence permit. Before and after the PERT course, the dynamics of anthropometric [body weight, body mass index (BMI)] and laboratory indicators of nutritional status (total protein, albumin, vitamins D and B12, transferrin, iron and magnesium) were evaluated. RESULTS After the completion of PERT, a significant tendency towards an increase in BMI in patients was noted in both groups. In group I, this indicator increased from 21.45 [95% confidence interval (CI) 19.80-23.92] kg/m2 to 22.15 (95% CI 20.31-23.86) kg/m2, and in II group - from 19.22 (95% CI 18.33-21.99) kg/m2 to 22.0 (95% CI 19.97-24.08) kg/m2. At the same time, the duration of PERT (months) significantly correlated with the dynamics of the patient's body weight (r=0.4679; 95% CI 0.2384-0.6479, p=0.0002). When assessing laboratory markers of nutritional status after PERT, a general tendency was found to increase the levels of total protein, albumin, vitamin D, magnesium, transferrin, and iron in both groups, however, statistically significant differences in the dynamics were observed mainly in group II patients. So, the level of total protein in group II increased from 69.05 (95% CI 65.6717-70.9000) g/l to 72.8 (95% CI 71.1358-74.9000) g/l, vitamin D - from 10.6 (95% CI 32.8397-38.9603) ng/ml to 17.1 (95% CI 12.0166-23.6232) ng/ml, magnesium - from 0.72 ( 95% CI 0.6892-0.7825) mmol/L to 0.795 (95% CI 0.7692-0.8800) mmol/L, and transferrin from 2.91 (95% CI 2.1800-3.3656 ) g/l to 2.92 (95% CI 2.4000-3.5200) g/l. CONCLUSION A prospective observational study demonstrated the effectiveness of PERT using microencapsulated pancreatin preparations in the correction of nutritional status in patients with CP.
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Affiliation(s)
- T V Bideeva
- Federal State Budgetary Educational Institution of the Higher Education "A.I. Yevdokimov Moscow State University of Medicine and Dentistry"
| | - I V Maev
- Federal State Budgetary Educational Institution of the Higher Education "A.I. Yevdokimov Moscow State University of Medicine and Dentistry"
| | - Y A Kucheryavyy
- Federal State Budgetary Educational Institution of the Higher Education "A.I. Yevdokimov Moscow State University of Medicine and Dentistry"
| | - D N Andreev
- Federal State Budgetary Educational Institution of the Higher Education "A.I. Yevdokimov Moscow State University of Medicine and Dentistry"
| | - Y S Shah
- Federal State Budgetary Educational Institution of the Higher Education "A.I. Yevdokimov Moscow State University of Medicine and Dentistry"
| | - E G Lobanova
- Federal State Budgetary Educational Institution of the Higher Education "A.I. Yevdokimov Moscow State University of Medicine and Dentistry"
| | - A V Zaborovskiy
- Federal State Budgetary Educational Institution of the Higher Education "A.I. Yevdokimov Moscow State University of Medicine and Dentistry"
| | - A I Levchenko
- Federal State Budgetary Educational Institution of the Higher Education "A.I. Yevdokimov Moscow State University of Medicine and Dentistry"
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Clement DSVM, Tesselaar MET, van Leerdam ME, Srirajaskanthan R, Ramage JK. Nutritional and vitamin status in patients with neuroendocrine neoplasms. World J Gastroenterol 2019; 25:1171-1184. [PMID: 30886501 PMCID: PMC6421241 DOI: 10.3748/wjg.v25.i10.1171] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/13/2019] [Accepted: 02/22/2019] [Indexed: 02/06/2023] Open
Abstract
Symptoms of gastroenteropancreatic located neuroendocrine neoplasms (GEP-NENs) are often related to food intake and manifest as abdominal pain or diarrhoea which can influence patients nutritional status. Malnutrition is common in cancer patients and influences quality of life, treatment options and survival but is also present in up to 40% of patients with GEP-NENs. As part of malnutrition there are often deficiencies in fat-soluble vitamins, mainly vitamin D. Little knowledge exists on trace elements. Several factors influence the development of malnutrition such as size and localisation of the primary tumour as well as metastases, side effects from treatment but also hormone production of the tumour itself. One of the main influencing factors leading to malnutrition is diarrhoea which leads to dehydration and electrolyte disturbances. Treatment of diarrhoea should be guided by its cause. Screening for malnutrition should be part of routine care in every GEP-NEN patient. Multidisciplinary treatment including dietician support is necessary for all malnourished patients with GEP-NENs.
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Affiliation(s)
- Dominique SVM Clement
- Neuroendocrine Tumour Unit, King’s College Hospital ENETS Centre of Excellence, London SE5 9RS, United Kingdom
| | - Margot ET Tesselaar
- Department of Medical Oncology, Netherlands Cancer Institute ENETS Centre of Excellence, Amsterdam 1066 CX, Netherlands
| | - Monique E van Leerdam
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | - Rajaventhan Srirajaskanthan
- Neuroendocrine Tumour Unit, King’s College Hospital ENETS Centre of Excellence, London SE5 9RS, United Kingdom
- Department of Gastroenterology, King’s College Hospital, London SE5 9RS, United Kingdom
| | - John K Ramage
- Neuroendocrine Tumour Unit, King’s College Hospital ENETS Centre of Excellence, London SE5 9RS, United Kingdom
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Shandro BM, Nagarajah R, Poullis A. Challenges in the management of pancreatic exocrine insufficiency. World J Gastrointest Pharmacol Ther 2018; 9:39-46. [PMID: 30397535 PMCID: PMC6212541 DOI: 10.4292/wjgpt.v9.i5.39] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/06/2018] [Accepted: 10/09/2018] [Indexed: 02/06/2023] Open
Abstract
Pancreatic exocrine insufficiency (PEI) occurs when the insufficient secretion or function of pancreatic enzymes leads to maldigestion, most commonly as a result of chronic pancreatitis and pancreatic cancer. The condition is associated with significant morbidity and reductions in quality of life, even in milder forms. The challenges in approaching this condition include the non-specific presentation of mild to moderate PEI, and the lack of a convenient, accurate diagnostic test in this cohort. Classical symptoms appear late in the disease, and the diagnosis should be considered before steatorrhoea develops. Direct pancreatic function tests are the reference standard for diagnosis, but are invasive and not widely available. The faecal elastase-1 (FE-1) stool test is widely available and has been shown to be as effective as the 13C-mixed triglyceride breath test in more advanced disease. We recommend a pragmatic diagnostic approach that combines clinical history, assessment of nutritional status and measurement of FE-1. The critical first step is to consider the diagnosis. Once the diagnosis is confirmed, pancreatic enzyme replacement therapy should be initiated. The variety of enzyme preparations and recommended dosing regimens can present a challenge when selecting an adequate initial dose. Non-response should be actively sought and addressed in a systematic manner. This article discusses these challenges, and presents a practical approach to the diagnosis and management of PEI.
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Affiliation(s)
- Benjamin Myles Shandro
- Department of Gastroenterology, St George’s University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, United Kingdom
| | - Rani Nagarajah
- Department of Gastroenterology, St George’s University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, United Kingdom
| | - Andrew Poullis
- Department of Gastroenterology, St George’s University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, United Kingdom
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Forsmark CE. Diagnosis and Management of Exocrine Pancreatic Insufficiency. ACTA ACUST UNITED AC 2018; 16:306-315. [PMID: 30027527 DOI: 10.1007/s11938-018-0186-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Recent studies have documented that many patients with pancreatic exocrine insufficiency (EPI) are not identified and are not treated with appropriate dosages of pancreatic enzyme replacement therapy. This review will summarize the approach to diagnosis, treatment, and monitoring for treatment effect and complications in patients with exocrine insufficiency. RECENT FINDINGS While chronic pancreatitis is the most commonly identified cause of EPI, pancreatic cancer and pancreatic surgery are increasingly important. The diagnosis of EPI remains challenging, but fecal elastase is the most clinically useful test. Treatment requires an understanding of the appropriate dosage and timing of enzyme replacement, but recent studies show that clinicians often do not have this understanding. Monitoring and prevention of complications of EPI is increasingly important, particularly osteopenia and osteoporosis. In those that fail to respond, coexistent small intestinal bacterial overgrowth should be considered. Many clinicians do not consider EPI in the differential diagnosis, and patients with EPI are routinely undertreated in the USA. Appropriate identification of those at risk and use of appropriate enzyme therapy, along with monitoring for metabolic complications of EPI, are essential to provide effective care for these patients.
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Affiliation(s)
- Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Box 100214, 1329 SW 16th St, Suite 5251, Gainesville, FL, 32610-0214, USA.
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