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Lewis DM, Rieke JG, Almusaylim K, Kanchibhatla A, Blanchette JE, Lewis C. Exocrine Pancreatic Insufficiency Dosing Guidelines for Pancreatic Enzyme Replacement Therapy Vary Widely Across Disease Types. Dig Dis Sci 2024; 69:615-633. [PMID: 38117426 DOI: 10.1007/s10620-023-08184-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/06/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Pancreatic enzyme replacement therapy (PERT) is the standard treatment for exocrine pancreatic insufficiency (EPI). However, many individuals are inadequately treated, with gaps in clinical dosing, guidelines, and tools to aid individual titration. METHODS A systematic review identified research and guidelines on PERT dosing recommendations across conditions, systematically reviewing and synthesizing total PERT intake, meal/snack guidelines, and changes over time to provide an up-to-date look at the most common doses used in studies and guidelines. RESULTS This review of 257 articles found wide variability in PERT dosing guidelines within and across conditions. Many patients with EPI are underdosed, with guidelines differing globally and by disease type, and clinician prescribing may also play a role. The most common dosing guidelines focus on starting doses at 40,000-50,000 units of lipase/meal with increases of up to two to three times this amount before pursuing additive therapies. Guidelines and studies typically focus only on fat digestion, and comparison by total daily dose shows underdosing is common. Most PERT studies are on safety and efficacy rather than optimal titration. CONCLUSION The current guidelines for PERT in EPI demonstrate substantial variability in dosing recommendations, both within and across disease types. This variation highlights the need for further research to optimize PERT dosing and improve patient outcomes. Healthcare providers should consider individualizing PERT dosing based on nutritional status and response to therapy, ensuring regular follow-up with patients for dose titrations with consideration that most guidelines are framed as initial doses rather than upper limits.
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Affiliation(s)
| | - Jorden G Rieke
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, 44106, USA.
| | - Khaleal Almusaylim
- Diabetes and Metabolic Care Center, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Anuhya Kanchibhatla
- Department of Arts and Sciences, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Julia E Blanchette
- Diabetes and Metabolic Care Center, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Claudia Lewis
- Diabetes and Metabolic Care Center, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA
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Naples R, Perlmutter BC, Thomas JD, McMichael J, Bottino R, Solomina J, Trucco M, Augustin T, Simon R, Walsh RM. Clinical Significance of Postoperative Antibiotic Treatment for Positive Islet Cultures After Total Pancreatectomy With Islet Autotransplantation. Pancreas 2021; 50:1000-1006. [PMID: 34629454 DOI: 10.1097/mpa.0000000000001874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Islet cultures are routinely performed in total pancreatectomy with islet autotransplantation (TPIAT), and the need for empiric antibiotic treatment based on culture results is unknown. We evaluated the effect of postoperative antibiotic treatment for positive islet cultures on clinical infection. METHODS Seventy-nine patients undergoing TPIAT were reviewed. Prophylactic perioperative ceftriaxone and metronidazole were administered, and transplanted islet preparations included ciprofloxacin. Postoperative antibiotics were not routinely given for positive cultures unless a clinical infection was suspected. The primary end point was 30-day infectious complications. RESULTS Fifty-one patients (65%) had a positive culture. Overall, 39 patients (87%) had organisms susceptible to our perioperative antibiotic regimen. There was no difference in the infectious complication rate between those with positive compared with negative cultures (16% vs 29%, P = 0.17). Patients with a positive culture had similar 30-day postoperative infectious complication rates whether receiving postoperative antibiotics (n = 7) or not (14% vs 16%, P = 0.91). Only 1 patient had a correlation of clinical and islet cultures. CONCLUSIONS Beyond prophylactic antibiotics, empiric antibiotic treatment for a positive culture is not warranted and provides a rationale for the abandonment of routine cultures in TPIAT.
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Affiliation(s)
- Robert Naples
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Breanna C Perlmutter
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Jonah D Thomas
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - John McMichael
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Rita Bottino
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Julia Solomina
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Massimo Trucco
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Toms Augustin
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Robert Simon
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - R Matthew Walsh
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Abstract
Chronic pancreatitis (CP) should be suspected in the case of recurrent upper abdominal pain of unknown origin and/or clinical signs of exocrine pancreatic insufficiency (EPI). Alcohol is the most common etiological factor associated with CP, others being smoking, male gender, and hereditary forms. CP is often associated with recurrent episodes of acute exacerbations.As of today, there is no accepted clinical definition of CP. However, irreversible morphological changes within the pancreas often occur, including dilatation of the main and branch pancreatic ducts, calcifications in ducts and parenchyma, parenchymal atrophy, and development of pseudocysts, though less so in the early phase of CP.
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4
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Li DF, Yao J, Li ZS, Bai Y. Pancreatic enzyme replacement for refractory multiple large pancreatic cysts. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 111:639-640. [PMID: 31317755 DOI: 10.17235/reed.2019.6030/2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The case was a 47-year-old male with a long history of alcohol abuse but he had stopped drinking alcohol after the first attack of acute pancreatitis. He was referred due to recurrent pancreatitis complicated by pancreatic pseudocysts. Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) imaging was suggestive of chronic pancreatitis and pancreatolithiasis, with multiple large pseudocysts in the head and tail of pancreas.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital, China
| | - Jun Yao
- Department of Gastroenterology, The 2nd Clinical medicine College (Shenzhen People's Hospital) of Jinan University
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, China
| | - Yu Bai
- Department of Gastroeterology, Changhai Hospital. Second Military Medical University. , China
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Berman A, Wszola M, Gorski L, Serwanska-Swietek M, Ostaszewska A, Lipinska A, Chmura A, Kwiatkowski A. Islet Autotransplantation in Diabetic Patients. Transplant Proc 2019; 51:2781-2786. [PMID: 31439326 DOI: 10.1016/j.transproceed.2019.04.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/02/2019] [Accepted: 04/13/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Painful chronic pancreatitis (CP) is the main indication for analgesic pancreatectomy with simultaneous islet autotransplantation to prevent postoperative diabetes mellitus (DM). However, advanced CP may lead to insulin secretion disorders and DM. There are doubts as to whether islet autotransplantation in such cases is an appropriate procedure. The aim of this study was to analyze the results of islet autotransplantation in patients with CP with already diagnosed with DM. METHOD Between 2008 and 2015, at the Department of General and Transplantation Surgery, patients with CP and unsatisfying pain treatment with positive fasting C-peptide ( > 0.3 ng/mL) level were qualified for simultaneous pancreatectomy and islet autotransplantation. Eight procedures were performed. In 5 cases patients had DM diagnosed prior to the procedure (DM group n = 5). Three patients without DM diagnosed prior to surgery were the control group (n = 3). RESULT There were no cases of procedure-related deaths in either group. Pain relief without analgesics was reported by all patients. Good islet function was observed in 80% (4/5) of the DM group vs 100% (3/3) in the control group (P = ns). Brittle diabetes was diagnosed in 1 patient in the DM group as a result of islet primary non-function. CONCLUSION Patients with CP-related severe pain and DM patients with positive C-peptides should be considered for pancreatectomy and islet autotransplantation.
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Affiliation(s)
- Andrzej Berman
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland; Foundation of Research and Science Development, Warsaw, Poland
| | - Michal Wszola
- Foundation of Research and Science Development, Warsaw, Poland.
| | - Lukasz Gorski
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | | | - Agata Ostaszewska
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Anna Lipinska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Chmura
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Artur Kwiatkowski
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
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Waldthaler A, Valente R, Arnelo U, Löhr JM. Endoscopic and Conservative Management of Chronic Pancreatitis and Its Complications. Visc Med 2019; 35:98-108. [PMID: 31192243 DOI: 10.1159/000499611] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/14/2019] [Indexed: 12/15/2022] Open
Abstract
Chronic pancreatitis is a progressive inflammatory disease of the pancreas potentially giving rise to several complications. For this reason, patients need long-term care and treatment by medical, interventional, and sometimes surgical measures. This article reviews current state-of-the-art strategies and guidelines for treating chronic pancreatitis with conventional and endoscopic measures.
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Affiliation(s)
- Alexander Waldthaler
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
| | - Roberto Valente
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
| | - J-Matthias Löhr
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
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Xu C, Shen J, Zhang J, Jia Z, He Z, Zhuang X, Xu T, Shi Y, Zhu S, Wu M, Han W. Recombinant interleukin-1 receptor antagonist attenuates the severity of chronic pancreatitis induced by TNBS in rats. Biochem Pharmacol 2015; 93:449-60. [PMID: 25559498 DOI: 10.1016/j.bcp.2014.12.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/23/2014] [Accepted: 12/23/2014] [Indexed: 12/16/2022]
Abstract
Chronic pancreatitis (CP) is a common disease in the department of gastroenterology, with the main symptoms of exocrine and/or endocrine insufficiency and abdominal pain. The pathogenic mechanism of CP is still not fully clarified and the aims of treatment now are to relieve symptoms. In this study, we attempted to find a connection between interleukin-1β (IL-1β) and interleukin-1 receptor antagonist (IL-1Ra) in trinitrobenzene sulfonic acid (TNBS)-induced chronic pancreatitis, and then the therapeutic effect of recombinant IL-1Ra was also detected in the CP model. Chronic pancreatitis was induced by intraductal infusion of TNBS in SD rats followed by a consecutive administration of rIL-1Ra, and the histological changes and collagen content in the pancreas were measured, as well as the abdominal hypersensitivity. We found that rhIL-1Ra could attenuate the severity of chronic pancreatic injury, modulate the extracellular matrix secretion, focal proliferation and apoptosis, and cellular immunity in TNBS-induced CP. Interestingly, rIL-1Ra could also block the pancreatitis-induced referred abdominal hypersensitivity. In conclusion, IL-1Ra may play a protective role in CP and rIL-1Ra would be a potential therapeutic target for the treatment of CP, while its possible mechanisms and clinical usage still need further investigation.
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Affiliation(s)
- Chunfang Xu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Jiaqing Shen
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China.
| | - Jing Zhang
- Central Research Institute, Shanghai Pharmaceuticals Holding Co. Ltd., Shanghai 200219, China
| | - Zhenyu Jia
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Zhilong He
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Xiaohui Zhuang
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Ting Xu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Yuqi Shi
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Shunying Zhu
- Shanghai Municipality Key Laboratory of Veterinary Biotechnology, School of Agriculture and Biology, Shanghai Jiaotong University, Shanghai 200240, China
| | - Mingyuan Wu
- Laboratory of Regeneromics, School of Pharmacy, Shanghai Jiaotong University, Shanghai 200240, China
| | - Wei Han
- Laboratory of Regeneromics, School of Pharmacy, Shanghai Jiaotong University, Shanghai 200240, China
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Chiang KC, Chen TH, Hsu JT. Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm. World J Gastroenterol 2014; 20:16132-16137. [PMID: 25473165 PMCID: PMC4239499 DOI: 10.3748/wjg.v20.i43.16132] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 06/08/2014] [Accepted: 07/25/2014] [Indexed: 02/07/2023] Open
Abstract
Chronic pancreatitis is an ongoing disease characterized by persistent inflammation of pancreatic tissues. With disease progression, patients with chronic pancreatitis may develop troublesome complications in addition to exocrine and endocrine pancreatic functional loss. Among them, a pseudoaneurysm, mainly induced by digestive enzyme erosion of vessels in proximity to the pancreas, is a rare and life-threatening complication if bleeding of the pseudoaneurysm occurs. At present, no prospective randomized trials have investigated the therapeutic strategy for this rare but critical situation. The role of arterial embolization, the timing of surgical intervention and even surgical procedures are still controversial. In this review, we suggest that dynamic abdominal computed tomography and angiography should be performed first to localize the bleeders and to evaluate the associated complications such as pseudocyst formation, followed by arterial embolization to stop the bleeding and to achieve early stabilization of the patient’s condition. With advances and improvements in endoscopic devices and techniques, therapeutic endoscopy for pancreatic pseudocysts is technically feasible, safe and effective. Surgical intervention is recommended for a bleeding pseudoaneurysm in patients with chronic pancreatitis who are in an unstable condition, for those in whom arterial embolization of the bleeding pseudoaneurysm fails, and when endoscopic management of the pseudocyst is unsuccessful. If a bleeding pseudoaneurysm is located over the tail of the pancreas, resection is a preferential procedure, whereas if the lesion is situated over the head or body of the pancreas, relatively conservative surgical procedures are recommended.
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MESH Headings
- Aneurysm, False/diagnosis
- Aneurysm, False/etiology
- Aneurysm, False/therapy
- Aneurysm, Ruptured/diagnosis
- Aneurysm, Ruptured/etiology
- Aneurysm, Ruptured/therapy
- Embolization, Therapeutic/adverse effects
- Hemostasis, Endoscopic/adverse effects
- Humans
- Pancreatectomy/adverse effects
- Pancreatitis, Chronic/complications
- Pancreatitis, Chronic/diagnosis
- Pancreatitis, Chronic/therapy
- Predictive Value of Tests
- Radiography, Abdominal/methods
- Risk Factors
- Tomography, X-Ray Computed
- Treatment Outcome
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9
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Olesen SS, Juel J, Nielsen AK, Frøkjær JB, Wilder-Smith OHG, Drewes AM. Pain severity reduces life quality in chronic pancreatitis: Implications for design of future outcome trials. Pancreatology 2014; 14:497-502. [PMID: 25455540 DOI: 10.1016/j.pan.2014.09.009] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 09/10/2014] [Accepted: 09/24/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Chronic pancreatitis (CP) is a disabling disease characterised by abdominal pain, and various pancreatic and extra-pancreatic complications. We investigated the interactions between pain characteristics (i.e. pain severity and its pattern in time), complications, and quality of life (QOL) in patients with CP. METHODS This was a cross-sectional study of 106 patients with CP conducted at two North European tertiary medical centres. Detailed information on clinical patient characteristics was obtained from interviews and through review of the individual patient records. Pain severity scores and pain pattern time profiles were extracted from the modified brief pain inventory short form and correlated to QOL as assessed by the EORTC QLQ-C30 questionnaire. Interactions with exocrine and endocrine pancreatic insufficiency, as well as pancreatic and extra-pancreatic complications were analysed using regression models. RESULTS Pain was the most prominent symptom in our cohort and its severity was significantly correlated with EORTC global health status (r = -0.46; P < 0.001) and most functional and symptom subscales. In contrast the patterns of pain in time were not associated with any of the life quality subscales. When controlling for interactions from exocrine and endocrine pancreatic insufficiency no effect modifications were evident (P = 0.72 and P = 0.85 respectively), while the presence of pancreatic and extra-pancreatic complications was associated with an almost 15% decrease in life quality (P = 0.004). CONCLUSIONS Pain severity and disease related complications significantly reduce life quality in patients with CP. This information is important in order to design more accurate and clinical meaningful endpoints in future outcome trials.
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Affiliation(s)
- Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Denmark.
| | - Jacob Juel
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Denmark
| | | | | | - Oliver H G Wilder-Smith
- Pain and Nociception Neuroscience Research Group, Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Centre, The Netherlands; Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Denmark; Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Denmark
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