Nutrition Support Blog: Panoply of Pertinent Pancreatitis Pearls
October 4, 2011
I recently blogged about the progress that we have witnessed in the medical and nutrition therapy provided to patients with pancreatitis. However, in one aspect of care it feels like we have taken several steps backwards. In April 2010, the FDA began to enforce their policy (first announced in 1991!) that all pancreatic enzyme products had to complete a new drug application or be removed from the market. As a result of this policy, certain products such as powdered pancrealipase, that had been available for years, were no longer available for sale in the United States. Currently, only 3 pancreatic enzyme products have been approved for sale (Creon, Zenpep and Pancreaze). See this link for more details on available products and dosing:
Pancrealipase powder had a limited number of clinical applications compared to the more effective enteric-coated products, so it is understandable that companies did not pursue the time-consuming and expensive new drug application for that particular product. One way that uncoated enzymes could be effectively utilized was to mix them into enteral feeding products delivered into the small bowel (where there was no gastric acid to destroy the enzymes). Our calculations revealed that it had been more cost effective (hospital costs) to use standard calorie-dense formulas with added enzymes than hydrolyzed or elemental formulas, but this is not true anymore.
It is important to note that not all patients with pancreatitis require enzymes or an elemental formula. A number of the key studies that demonstrated the superiority of jejunal EN over PN actually used standard polymeric formulas.1-3 Although elemental formulas stimulate the pancreas less than polymeric formulas when fed into the stomach or duodenum, when polymeric formulas were fed well below the ligament of Treitz, there was less pancreatic stimulation than TPN.4
We found that in a population of 127 patients with severe pancreatitis complicated by large pseudocysts and/or necrotic pancreatic tissue, that only 1/3 of the patients had a positive fecal fat (malabsorption) while receiving a standard formula.5 Our practice is to use polymeric formulas as the initial feeding, and only change to a semi-elemental formula in those patients that experience malabsorption. If a patient has diarrhea after starting EN we first look for C. Difficile, followed by cathartic medications, sorbitol-containing liquid or elixir meds, or contrast from the CT scan as a possible cause. Only after “rounding up the usual suspects” do we check fecal fat for malabsorption. It is helpful to document if your patient actually has pancreatic exocrine insufficiency before using a hydrolyzed formula so that attention to fat-soluble vitamin dosing, bone health concerns (malabsorbed fats + calcium in GI tract = soap; remember “saponification” from biochem?), and other potential long-term nutrition issues can be addressed. If you “fix” the diarrhea by an empiric change to an elemental EN formula you will often find that no mention is made of malabsorption or pancreatic exocrine insufficiency in the discharge summary or the patient’s medical history.
The unavailability of powdered pancreatic enzymes does limit our flexibility for formula choice. The use of powdered enzymes had previously allowed us to utilize the higher-protein, calorie-dense, or even reduced-electrolyte “renal” formulas when necessary in those patients with exocrine insufficiency. Luckily most patients do fine with standard polymeric formulas.
1. Windsor AC, Kanwar S, Li AG, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut. 1998;42:431–435.
2. Pupelis G, Selga G, Austrums E, Kaminski A. Jejunal feeding, even when instituted late, improves outcomes in patients with severe pancreatitis andperitonitis. Nutrition.2001;17:91–914.
3. Modena JT, Cevasco LB, Basto CA, et al. Total enteral nutrition as prophylactic therapy for pancreatic necrosis infection in severe acute pancreatitis. Pancreatology. 2006;6:58-64.
4. Kaushik N, Pietraszewski M, Holst JJ, O'Keefe SJ. Enteral feeding without pancreatic stimulation. Pancreas. 2005;31:353-359.
5. Makola D, Krenitsky J, Parrish C, et al. Efficacy of enteral nutrition for the treatment of pancreatitis using standard enteral formula. Am J Gastroenterol. 2006;101(10):2347-2355.
“Now, good digestion wait on appetite, and health on both!”
- William Shakespeare