Options for addressing exocrine pancreatic insufficiency in patients receiving enteral nutrition supplementation

Patients with exocrine pancreatic insufficiency (EPI) have suboptimal secretion of pancreatic digestive enzymes and experience a range of clinical symptoms related to the malabsorption of fat. In patients with EPI unable to meet their nutritional requirements, enteral nutrition (EN) support is used to augment nutritional status. In addition to protein and carbohydrate, EN formulas contain fats as a calorie source, as well as vitamins and minerals to help prevent nutritional deficiencies related to malabsorption. Semielemental enteral nutrition formulas are advantageous as they contain hydrolyzed protein, shorter chain carbohydrates, and may contain medium chain triglycerides as a fat source. However, severely pancreatic insufficient patients may be unable to absorb complex long-chain triglycerides provided by EN formulas due to insufficient pancreatic lipase; replacement pancreatic enzyme products are recommended for these patients. Currently, none of the FDA-approved pancreatic enzyme replacement therapy (PERT) products are indicated for use in patients receiving enteral nutrition and administration of enzymes by mixing into enteral nutrition formula is not supported by guidelines as this route is associated with risks. RELiZORB (immobilized lipase) is a novel in-line digestive cartridge that has been designed to address the unmet need for PERT in patients receiving enteral nutrition. RELiZORB efficacy and compatibility with a range of commercially available polymeric and semielemental formulas with varying nutrient, caloric content, and triglyceride chain lengths have been demonstrated. In most formulas, RELiZORB efficiently hydrolyzed greater than 90% of fats within the formula into absorbable fatty acids and monoglycerides.

Characterization and Applications of Marine Microbial Enzymes in Biotechnology and Probiotics for Animal Health

Marine microorganisms have been recognized as potential sources of novel enzymes because they are relatively more stable than the corresponding enzymes derived from plants and animals. Enzymes from marine microorganisms also differ from homologous enzymes in terrestrial microorganisms based on salinity, pressure, temperature, and lighting conditions. Marine microbial enzymes can be used in diverse industrial applications. This chapter will focus on the biotechnological applications of marine enzymes and also their use as a tool of marine probiotics to improve host digestion (food digestion, food absorption, and mucus utilization) and cleave molecular signals involved in quorum sensing in pathogens to control disease in aquaculture.

Enzymatic Polymerization of an Ibuprofen-Containing Monomer and Subsequent Drug Release

Novel ibuprofen-containing monomers comprising naturally occurring and biocompatible compounds were synthesized and subsequently polymerized via enzymatic methods. Through the use of a malic acid sugar backbone, ibuprofen was attached as a pendant group, and then subsequently polymerized with a linear aliphatic diol (1,3-propanediol, 1,5-pentanediol, or 1,8-octanediol) as comonomer using lipase B from Candida antarctica, a greener alternative to traditional metal catalysts. Polymer structures were elucidated by nuclear magnetic resonance and infrared spectroscopies, and thermal properties and molecular weights were determined. All polymers exhibited sustained ibuprofen release, with the longer chain, more hydrophobic diols exhibiting the slowest release over the 30 d study. Polymers were deemed cytocompatible using mouse fibroblasts, when evaluated at relevant therapeutic concentrations. Additionally, ibuprofen retained its chemical integrity throughout the polymerization and in vitro hydrolytic degradation processes. This methodology of enzymatic polymerization of a drug presents a more environmentally friendly synthesis and a novel approach to bioactive polymer conjugates.

[Cholestasis and pancreatic insufficiency: how to start treatment?]

The article presents a detailed analysis of pathogenesis and clinical manifestation of secondary pancreatic excretory insufficiency due to disorders of bile production and choleresis. Pathogenesis of hepatogenic (chologenic) pancreatic insufficiency considered in view of impairment of bile acids' different functions in cholestasis. Authors review pathology of liver and bile ducts resulted in steatorrhea. It was conducted pathogenetic substantiation treatment tactics of patients, which have a combination of cholestasis and secondary pancreatic insufficiency.

[Eurand Minitabs--the innovative application formula of a pancreatic enzyme complex (Pangrol 10,000, 25,000)]

Modern technology of solid oral drug forms, through the application of macromolecular polymers, generates a number of new formulation solutions. New technologies provide optimal parameters for the release of biologically active substances, increasing by these means pharmacotherapeutic effectiveness of a medicinal product. Basic properties of the innovative Eurand Minitabs technology, making possible the tableting of technologically and applicatively labile substances such as a pancreatic enzyme complex were dicussed. The application of encapsulated minitablets coated with a methacrylic acid copolymer guarantees an optimal range of lipase pharmacological activity.

Effects of intestinal constituents and lipids on intestinal formation and pharmacokinetics of desethylamiodarone formed from amiodarone

To model the impact of intestinal components associated with a high fat meal on metabolism of amiodarone, rat everted intestinal sacs were evaluated for their ability to metabolize the drug to its active metabolite (desethylamiodarone) under a variety of conditions. The preparations were obtained from fasted rats or rats pretreated with 1% cholesterol in peanut oil. After isolation of the tissues, the intestinal segments were immersed in oxygenated Krebs Henseleit buffer containing varying concentrations of bile salts, cholesterol, lecithin and lipase with or without soybean oil emulsion as a source of triglycerides. Amiodarone uptake was similar between the five 10-cm segments isolated distally from the stomach. Desethylamiodarone was measurable in all segments. Based on the metabolite-to-drug concentration ratio within the tissues, there was little difference in metabolic efficiency between segments for any of the treatments. Between treatments, however, it appeared that the lowest level of metabolism was noted in rats pretreated with 1% cholesterol in peanut oil. This reduction in metabolic efficiency was not observed in gut sacs from the fasted rats to which soybean oil emulsion was directly added to the incubation media. Despite the apparent reduction in intestinal metabolism, there was no apparent change in the ratio of metabolite-to-drug area under the plasma concentration versus time ratios of fasted rats and those given 1% cholesterol in peanut oil, suggesting that the intestinal presystemic formation of desethylamiodarone is not substantial.

Controlling cartilaginous matrix evolution in hydrogels with degradation triggered by exogenous addition of an enzyme

Crosslinked hydrogels provide an accommodating environment for cartilage regeneration. However, degradation of the crosslinked network is necessary to create gels with an initially desirable mechanical stiffness and long-term distribution of properly assembled matrix molecules. In this study, chondrocytes were encapsulated in crosslinked poly(ethylene glycol) (PEG) hydrogels with caprolactone blocks that enabled an exogenously controlled, enzymatic degradation mechanism. At different stages of in vitro culture, a lipase enzyme was added to culture media to trigger degradation of the gel network. In gel constructs that never received lipase, the large cartilage matrix molecule, type II collagen, was localized to the pericellular region. Constructs that received lipase in the media for at least 1 week degraded enough to allow some distribution of collagen, but the timing and duration of lipase administration affected the outcome of regenerated tissue after 8 weeks of in vitro culture. Degradation that was triggered too early resulted in more significant defects in the cartilaginous matrix. The hydrogels applied in this study allow explicit control over degradation, and therefore provide a useful tool for investigating the effects of specific mass loss profiles on the evolution of neocartilage in vitro.

Study of a novel pancreatic enzyme replacement therapy in pancreatic insufficient subjects with cystic fibrosis

OBJECTIVES

We studied a novel pancreatic enzyme product, ALTU-135, a proprietary formulation of microbially derived lipase, protease, and amylase, to determine its efficacy and safety in treatment of pancreatic insufficiency (PI) in patients with cystic fibrosis (CF).

STUDY DESIGN

Ambulatory subjects with CF-PI (n = 117) had baseline coefficient of fat and nitrogen absorption (CFA and CNA, respectively) determined in an inpatient setting while not receiving pancreatic enzyme replacement therapy. Subjects were then randomized to treatment with ALTU-135 containing 5000 (low), 25,000 (mid), or 100,000 (highest) units of lipase (1:1:0.15 of lipase:protease:amylase) for 28 days. After 14 days, CFA and CNA were re-measured. The primary outcomes were change from baseline in CFA and CNA between treatments.

RESULTS

Treatment CFA was significantly greater in the mid and highest dose groups compared with that in the low dose group (P = .0229 and P =.0041, respectively); findings were similar for CNA. Subjects with baseline CFA < or = 40% and > 40% in the 2 higher dose groups had a mean increase of 31 and 8 percentage points in CFA, respectively (P < .0001).

CONCLUSION

ALTU-135 was efficacious during the 1-month study period at the dose of 25,000 units of lipase, 25,000 units of protease, and 3750 units of amylase.

Meal patterns, dietary fat intake and pancreatic enzyme use in preadolescent children with cystic fibrosis

OBJECTIVES

To describe the usual pattern of intake and adherence to cystic fibrosis (CF) food and pancreatic enzyme replacement therapy (PERT) recommendations in preadolescent children with CF and pancreatic insufficiency (PI).

METHODS

Children, 8 to 11 years old, with CF and PI were assessed for PERT adherence ratio (number taken/number prescribed per day) and energy and fat intake for 7 days (weighed food records), adherence to PERT and dietary recommendations, pulmonary function, growth status and stool fat malabsorption. Using the PERT adherence ratio, children were divided into good (> or =80%), moderate (60% to 79%) and poor (<60%) adherence groups.

RESULTS

Of the 75 children (age, 9.3 +/- 1.0 years; forced expiratory volume in 1 s, 95 +/- 14% predicted), 61% consumed less than 120% of energy intake, and 72% consumed less than 40% of calories as fat recommended for CF. Using the PERT adherence ratio (mean +/- SD, 75 +/- 14%), 29%, 61% and 9% of children had good, moderate and poor adherence, respectively. Better adherence to PERT was significantly associated with missing fewer snacks, higher energy intake, greater fat content of snacks and poorer growth status. About 85% of the children were in the 500 to 4000 lipase unit (LU) of PERT (LU/g fat per day) and 500 to 2500 LU/kg per body weight per meal guidelines, whereas only 58% to 68% were within the guidelines for snacks. Eleven percent of children always took PERT at an inappropriate time after meals.

CONCLUSIONS

Most preadolescent children with CF and PI did not meet dietary recommendations. Future educational and behavioral interventions focused on increasing PERT adherence with snacks, fat content of meals and snacks, appropriate timing of enzymes and adjustment of PERT and meal fat content are suggested.

Safety and preliminary clinical activity of a novel pancreatic enzyme preparation in pancreatic insufficient cystic fibrosis patients

OBJECTIVES

Currently available pancreatic enzyme products are crude porcine products with few data available regarding their efficacy, safety, and manufacture. We conducted a phase 1 study of a novel pancreatic enzyme product, TheraCLEC-Total (TCT), a proprietary formulation of microbial-derived lipase, protease, and amylase, to determine its safety and preliminary efficacy in cystic fibrosis.

METHODS

We conducted an open-label, dose-ranging study in 23 subjects diagnosed with pancreatic insufficiency with cystic fibrosis. The subjects received TCT containing lipase dose of 100, 500, 1000, 2500, or 5000 USP U/kg per meal with each meal or snack for 3 days. The clinical and laboratory parameters and adverse events (AEs) were monitored.

RESULTS

There were no serious AEs. Most AEs were mild, although gastrointestinal complaints were common. TCT increased the coefficient of fat and nitrogen absorption in all groups except in the low-dose group. At the other dosing levels, the mean coefficient of fat and nitrogen absorption increases were 19.1% +/- 24.9% and 17.8% +/- 13.6%, respectively, whereas the mean stool weight decreased by 517 +/- 362 g.

CONCLUSIONS

TCT was well tolerated in this short-term exposure study. The preliminary efficacy data demonstrate lipase and protease activity with little difference seen with lipase doses greater than 500 USP U/kg per meal. These data support a larger randomized phase 2 trial.

Fibrocalculous pancreatic diabetes in patient residing in the Mediterranean region

A 40-year old male residing in the Mediterranean region and afflicted with chronic pancreatitis and diabetes is presented. This is a case of chronic calcific non-alcoholic pancreatitis with characteristic intraductal calculi on abdominal X-ray. Five years following the initial episode of pancreatitis, the patient developed insulin-requiring diabetes mellitus. This case accords with the criteria for fibrocalculous pancreatic diabetes with the unique feature of the patient having been born in Greece and being a resident of Greece.

The role of mannosylated enzyme and the mannose receptor in enzyme replacement therapy

Lysosomal acid lipase (LAL) is the critical enzyme for the hydrolysis of triglycerides (TGs) and cholesteryl esters (CEs) in lysosomes. LAL defects cause Wolman disease (WD) and CE storage disease (CESD). An LAL null (lal-/-) mouse model closely mimics human WD/CESD, with hepatocellular, Kupffer cell and other macrophage, and adrenal cortical storage of CEs and TGs. The effect on the cellular targeting of high-mannose and complex oligosaccharide-type oligosaccharide chains was tested with human LAL expressed in Pichia pastoris (phLAL) and CHO cells (chLAL), respectively. Only chLAL was internalized by cultured fibroblasts, whereas both chLAL and phLAL were taken up by macrophage mannose receptor (MMR)-positive J774E cells. After intraperitoneal injection into lal-/- mice, phLAL and chLAL distributed to macrophages and macrophage-derived cells of various organs. chLAL was also detected in hepatocytes. Ten injections of either enzyme over 30 d into 2- and 2.5-mo-old lal-/- mice produced normalization of hepatic color, decreased liver weight (50%-58%), and diminished hepatic cholesterol and TG storage. Lipid accumulations in macrophages were diminished with either enzyme. Only chLAL cleared lipids in hepatocytes. Mice double homozygous for the LAL and MMR deficiences (lal-/-;MMR-/-) showed phLAL uptake into Kupffer cells and hepatocytes, reversal of macrophage histopathology and lipid storage in all tissues, and clearance of hepatocytes. These results implicate MMR-independent and mannose 6-phosphate receptor-independent pathways in phLAL uptake and delivery to lysosomes in vivo. In addition, these studies show specific cellular targeting and physiologic effects of differentially oligosaccharide-modified human LALs mediated by MMR and that lysosomal targeting of mannose-terminated glycoproteins occurs and storage can be eliminated effectively without MMR.

Combining unprotected pancreatic enzymes with pH-sensitive enteric-coated microspheres does not improve nutrient digestion in patients with cystic fibrosis

OBJECTIVES

To assess the efficacy of combining unprotected powder enzymes and oral enteric-coated microsphere (ECM) and to ECM alone in treating nutrient maldigestion in patients with cystic fibrosis.

STUDY DESIGN

Patients were randomly assigned into 2 consecutive, 2-week phases; ECM alone, and ECM plus unprotected powder enzymes. Fecal fat, energy, and nitrogen output were compared with intake at the end of each phase. Two-tailed, paired t tests were performed to compare outcomes.

RESULTS

The mean age of the 14 patients (3 girls) was 5.7 +/- 3.2 years (range, 1.9 to 13.4 years). There was no significant difference in percent malabsorption of fat (15.6% vs 18.2%), energy (13.3% vs 13.4%), or nitrogen (11.8% vs 11.3%) between phases.

CONCLUSIONS

The addition of powder enzymes to ECM did not improve nutrient maldigestion compared with ECM alone.

Ultrase MT12 and Ultrase MT20 in the treatment of exocrine pancreatic insufficiency in cystic fibrosis: safety and efficacy

BACKGROUND

Cystic fibrosis causes exocrine pancreatic insufficiency, leading to malabsorption. Supplemental pancreatic enzyme therapy alleviates the concomitant malnutrition experienced by cystic fibrosis patients. It is recognized that patients experience variations in clinical response to different brands of enzymes. This has prompted the US Food and Drug Administration to require that enzyme supplements be subjected to New Drug Applications.

AIM

To investigate the safety and efficacy of supplemental pancreatic enzyme therapy in cystic fibrosis subjects.

METHODS

We compared two doses of one formulation of enteric-coated pancreatic enzymes: Ultrase MT12 (12,000 lipase units per capsule) and Ultrase MT20 (20,000 lipase units per capsule), to placebo in two separate safety and efficacy studies.

RESULTS

Mean total fat, protein and carbohydrate intake did not differ significantly between the groups. A significant difference in both fat and protein absorption occurred with the enzyme therapy groups. The Ultrase MT12 and Ultrase MT20 groups experienced a mean fat and protein absorption 79.4% and 83.8%, and 87.3% and 88.6%, respectively. No adverse events related to study drug were reported.

CONCLUSIONS

This study further supports the use of enzymes to treat pancreatic insufficiency in cystic fibrosis. Excellent fat and protein absorption was achieved with minimal adverse events and safe doses.

Changes in lipid fractions and sensory properties of Idiazabal cheese induced by lipase addition

This work studied the addition of an adequate lipase to enhance lipolysis reactions and the development of piquant flavour and sharp odour in Idiazabal cheese, as an alternative to the use of lamb rennet paste. Cheeses were manufactured from bulk raw ewes' milk in 50 l vats with commercial bovine rennet and 80 lipase units of pregastric or 180 lipase units of fungal lipase and ripened for 180 days. A higher lipolytic activity was induced by lipase addition promoting strong changes in odour and flavour attributes. Both fungal and pregastric lipases increased the content of total free fatty acids (FFA), but the fungal lipase released mainly medium- and long-chain FFA. In contrast, the pregastric lipase preferably released short-chain FFA. Diglyceride (DG) content was considerably higher in cheeses made with added pregastric lipase compared with those made with fungal lipase or with no lipase. Monoglycerides (MG) were detected only in cheeses made with either lipase added, reaching comparable concentrations after ripening for 180 days. The cheeses made with pregastric lipase had the highest scores for odour and flavour intensity, and sharp and rennet odours, desirable attributes for the Idiazabal cheese made with lamb rennet paste. None of the texture attributes were significantly influenced by the concentrations of MG and DG in the cheeses made with either lipase. Thus, the pregastric lipase was more appropriate than the fungal lipase to develop a more traditionally-flavoured Idiazabal cheese.

The Effect of Fat Type, Carbohydrase, and Lipase Addition on Growth Performance and Nutrient Utilization of Young Broilers Fed Wheat-Based Diets

A 2 x 2 x 2 factorial experiment was conducted to evaluate the effects of fat type (beef tallow [50 g/kg diet] or canola oil [50 g/kg of diet]), carbohydrase addition (none or carbohydrases [0.4 g/kg diet]), and lipase addition (none or lipase [0.2 g/kg of diet]) on growth performance and nutrient utilization of male broilers fed a wheat-based diet from 5 to 18 d. The carbohydrase supplement contained xylanase, glucanase, cellulase, and other enzyme activities. The experimental diets were formulated to be suboptimal in major nutrients and each was fed in a mash form to 10 replicate pens of 5 broilers per pen. Body weight gain was not affected by fat type but a poorer feed/gain ratio (P < 0.001) was noted for tallow-containing diets. Regardless of fat type, carbohydrase enzyme supplementation improved (P < 0.001) BW gain and feed/gain ratio. There was no effect of lipase addition on chicken performance and nutrient utilization. When compared with canola oil, tallow-containing diets had a lower (P < 0.001) apparent fat digestibility and consequently a lower dietary AMEn content. Carbohydrase enzyme addition improved (P < 0.001) fat, starch, nitrogen, and nonstarch polysaccharide (NSP) digestibilities in the small intestine, improved AMEn, and reduced (P < 0.001) jejunal digesta viscosity in both fat types. Carbohydrase supplementation increased water-soluble (P < 0.001) and decreased water-insoluble (P < 0.001) NSP concentrations in the small intestine. The interaction between fat type and carbohydrase addition was only significant for fat digestibilities, with greater improvements seen for diets containing tallow. Significant interactions between carbohydrase addition and intestinal segment were noted for fat, starch, nitrogen, and NSP digestibilities, with the enzyme effects being greater in the jejunum than the ileum. It is evident from the present study that an appropriate carbohydrase preparation could eliminate the negative effects of soluble NSP on animal fat utilization in a wheat-based broiler diet.

Effects of preparative parameters on the properties of chitosan hydrogel beads containing Candida rugosa lipase

The influences of the pH, tripolyphosphate (TPP) concentration, and ionic strength of the gelling medium on the entrapment efficiency, release, and activity of lipase in chitosan hydrogel beads were studied. A solution of Candida rugosa lipase was prepared in a 1.5% w/v chitosan and 1% (v/v) acetic acid medium, and dropped into a TPP solution. Release of lipase in pH 7.2 Tris buffer was monitored over 36 h using the micro BCA protein assay. The activity of the entrapped enzyme was assayed using the Sigma lipase activity method. Following preliminary studies, an experimental design was followed to develop mathematical models that describe bead characteristics as functions of the pH and the TPP concentration in the gelling medium. The pH and the TPP concentration each had an effect on the entrapment, retention, and activity of lipase. Entrapped lipase retained a high degree of activity in multiple reactions. The ionic strength, in the range studied, exerted a minimal effect on bead characteristics. Statistical analysis allowed optimization within the factor space with respect to maximizing the enzyme entrapment efficiency and activity, and also minimizing the amount released after 36 h in the Tris buffer.

Evaluation of dietary fiber intake in Belgian children with cystic fibrosis: is there a link with gastrointestinal complaints?

BACKGROUND

Pancreatic enzyme replacement is the cornerstone of treating pancreatic insufficiency in patients with cystic fibrosis. Additionally, a high-calorie/high-fat diet is required to compensate for the increased energy requirement and the incomplete fat digestion. Even with adequate enzyme treatment, gastrointestinal problems, varying from simple constipation to inspissated stools, and distal intestinal obstruction syndrome (DIOS) may occur. Apart from residual fat malabsorption, a low fiber intake is suspected to be an underlying factor in gastrointestinal complaints.

METHODS

We evaluated fiber intake in 40 patients with cystic fibrosis based on the dietary history method. Patients were classified according to gastrointestinal problems: group 1, no gastrointestinal complaints; group 2, nonspecific and mild gastrointestinal complaints; and group 3, documented DIOS.

RESULTS

Overall fiber intake was adequate when compared with current recommendations. We could not show a relation between fiber intake and gastrointestinal complaints or DIOS. On the contrary, in patients with DIOS, fiber intake was higher, possibly as a therapeutic response to their gastrointestinal complaints.

CONCLUSION

Overall fiber intake is adequate in our cystic fibrosis population. We could show no relation between low fiber intake and gastrointestinal problems in our patients with cystic fibrosis.

Alpha amylase is a major allergenic component in occupational asthma patients caused by porcine pancreatic extract

Porcine pancreatic extracts (PPE) are composed of alpha-amylase and lipase, which are common components of digestive enzymes. They have been known to cause occupational asthma in exposed workers in pharmaceutical and baking industries, as well as in a laboratory technician, but there has been no report of PPE-induced occupational asthma in medical personnel and their IgE binding components to each component. Four asthmatic subjects showing positive results on PPE-bronchoprovocation testing were enrolled. All of them were nurses working in a university hospital. Their job included grinding and mixing PPE powder for admitted patients. Serum-specific IgE antibodies to PPE, alpha-amylase, and lipase were measured by enzyme linked immunosorbent assay (ELISA). To confirm specificity of IgE binding and cross-allergenicity among the three extracts, ELISA inhibition tests were performed. In order to characterize allergenic components within these three extracts, SDS-PAGE and IgE immunoblot analysis were done. Specific IgE antibodies to PPE, alpha-amylase, and lipase were detectable by ELISA in all study subjects. An alpha-amylase ELISA inhibition test showed significant inhibitions by amylase and PPE, and minimal inhibition by lipase. However, a lipase ELISA inhibition test showed significant inhibitions by alpha-amylase and PPE with a lesser degree of inhibition by lipase. Furthermore, IgE immunoblot analysis showed one IgE binding component (55 kDa) within PPE, six components (55 kDa, 43 kDa, 41 kDa, 32 kDa, 31 kDa, 29 kDa) within alpha-amylase and two components (31 kDa, 29 kDa) within lipase extracts. Thesefindings suggest that inhalation of PPE powder can induce IgE-mediated bronchoconstriction in exposed nurses. Alpha-amylase is a major allergenic component within PPE.

[Quality of life in the course of enzyme replacement therapy for chronic pancreatitis]

AIM

The ultimate goal of any treatment in chronic pancreatitis is to maximize the patient's quality of life. The authors evaluated the QoL of patients with chronic pancreatitis prior to and after pancreatic enzyme replacement therapy in a prospective, multicenter, follow-up study.

PATIENTS AND METHODS

Two groups of patients were evaluated. Group 1: 31 patients with newly diagnosed chronic pancreatitis who had never been treated with pancreatic enzyme preparations; Group 2: 39 patients whose disease was diagnosed on average 3.4 years before the start of the study. The latter group of patients had undergone pancreatic enzyme replacement therapy, but during the follow-up this proved to be insufficient. The dose of pancreatic enzyme replacement therapy was tailored in accordance with the degree of pancreatic exocrine insufficiency measured by means of exocrine pancreatic function tests.

RESULTS

A significant gain in body weight and a significantly reduced defecation rate were found in both groups 1 month after the beginning of the pancreatic enzyme replacement therapy as compared to the pretreatment values. The prevalence of general and disease-specific symptoms, and the intensity of pain were reduced in both groups after 1 month of enzyme substitution therapy. The working ability, the emotional functioning, the financial strain and the overall QoL score were improved significantly in both groups, while the cognitive functioning was found to be significantly improved during the follow-up only in Group 1. The overall increase in the QoL score correlated significantly with the increase in body weight and the decrease in defecation number in both groups.

CONCLUSIONS

Individually-tailored enzyme replacement therapy improved the QoL, reduced the extents of steatorrhea and pain, increased the body weight, not only in the untreated chronic pancreatitis patients, but even in the inadequately treated group.

Diminished and erratic absorption of ergocalciferol in adult cystic fibrosis patients

BACKGROUND

Osteoporosis diminishes the quality of life in adults with cystic fibrosis (CF). Vitamin D deficiency resulting from malabsorption may be a factor in the etiology of low bone mineral density (BMD) in patients with CF.

OBJECTIVE

Absorption of oral ergocalciferol (vitamin D2) and the consequent response of 25-hydroxyvitamin D in 10 adults with CF and exocrine pancreatic insufficiency was compared with that of 10 healthy control subjects.

DESIGN

In this pharmacokinetic study, CF patients and control subjects were pair-matched on age, sex, and race. Each subject consumed 2500 microg oral vitamin D2 with a meal. The CF group also took pancreatic enzymes that provided > or = 80000 U lipase. Blood samples were obtained at baseline and at 5, 10, 24, 30, and 36 h after vitamin D2 consumption to measure serum vitamin D2 and 25-hydroxyvitamin D concentrations.

RESULTS

Vitamin D2 concentrations in all subjects were near zero at baseline. CF patients absorbed less than one-half the amount of oral vitamin D2 that was absorbed by control subjects (P < 0.001). Absorption by the CF patients varied greatly; 2 patients absorbed virtually no vitamin D2. The rise in 25-hydroxyvitamin D in response to vitamin D2 absorption was significantly lower over time in the CF group than in the control group (P = 0.0012).

CONCLUSIONS

Vitamin D2 absorption was significantly lower in CF patients than in control subjects. These results may help explain the etiology of vitamin D deficiency in CF patients, which may contribute to their low BMD.

Ursodeoxycholic acid ameliorates ibuprofen-induced enteropathy in the rat

BACKGROUND

The objective of the study was to determine whether ursodeoxycholic acid (Ursodiol) is protective against ibuprofen (IBU)-induced enteropathy.

METHODS

Using the chronically catheterized rat model, IBU (60 mg/kg body weight per day) was infused via the gastric catheter twice daily. Pancreatic enzyme (PE; 10,000 U lipase/kg body weight per day) and Ursodiol (10 mg/kg body weight per day) in two doses were infused via the duodenal catheter. Rats were assigned to one of six treatment groups and were administered treatment for 20 days: control, IBU, PE, IBU + PE, IBU + Ursodiol, and IBU + PE + Ursodiol. The entire jejunum, ileum, cecum, and colon were available for histologic analysis using previously described techniques.

RESULTS

Addition of Ursodiol to high-dose IBU and normal doses of PE showed a significant reduction in the percentage of rats with ulcers (P < 0.05), total number of serositis events (P < 0.01), total number of severe ulcers (P < 0.001), and an absence of ulcers in the large intestine.

CONCLUSIONS

Ursodiol, the drug of choice for the treatment of cystic fibrosis liver disease, may offer a safe method of using high-dose IBU in these patients by ameliorating the enteropathy.

Early detection of impaired glucose tolerance in patients with cystic fibrosis and predisposition factors

INTRODUCTION

The number of patients with glucose tolerance alterations associated with cystic fibrosis (CF) has increased, probably due to the greater survival rate among sufferers of this disease. We studied impaired glucose tolerance (IGT) in patients with CF and investigated whether its appearance has any relationship with age, sex, genetic mutation and/or the degree of clinical involvement. We assessed the parameters that might allow early detection.

PATIENTS AND METHODS

In 28 patients with CF (14 M, 14 F; aged 22 months to 18 years), sex, genetic mutation, nutritional status and the degree of pancreatic and pulmonary involvement were recorded. The metabolic study included glycosylated hemoglobin (HbA1c) determination, oral glucose tolerance test (OGTT) and intravenous glucose tolerance tests (IVGTT).

RESULTS

In the patients with CF, 35.71% showed impaired glucose tolerance (IGT) and 3.57% had diabetes mellitus. The patients with IGT and CF were 3.2 years older than those with normal glucose tolerance (NGT; p<0.05), but no significant differences were found regarding sex, anthropometric measurements, percentage of pulmonary gammagraphic involvement, Shwachman-Kulczycki test or HbA1c. In the OGTT, the patients homozygous for the deltaF508 mutation had higher blood glucose values than the heterozygous group (p=0.03), but these values were not higher than those in patients with other mutations. During the OGTT, blood insulin values at 30' were reduced in patients with IGT compared to patients with NGT (p<0.02) and the insulin peak occurred at 100.9+/-24.3 min compared to 65.3+/-21.8, respectively (p<0.05). In the IVGTT, 82.14% of the patients had reduced insulin levels at 1 and 3 min (I1'+3'). No differences in the blood glucose levels during the OGTT were found between patients with normal I1'+3' values and patients with reduced values.

CONCLUSIONS

A high percentage of patients with CF also present with IGT. This increases with age and is more common among patients homozygous for the deltaF508 mutation and is not related to clinical status. Alterations in the kinetics of insulin secretion play an important role in the appearance of IGT and CF. We suggest that the OGTT is a more sensitive method than IVGTT for identifying early alterations in CF-related diabetes mellitus.

Effect of dietary lipase enzyme on gut morphology, gastric motility, and long-term performance of broiler chicks

Three experiments were conducted to test a previously described anorexic effect of graded dietary supplements of Pancreatic lipase enzyme on gut structure, gastric motility, and long-term performance of broiler chicks. In Experiment 1, dietary Pancreatic enzyme was used at graded levels of 0, 0.214, 0.429, 0.643, 0.857, and 1.071% to test the effect of this enzyme on gut structure, whereas Experiment 2 was designed to test its effect at 0, 0.268, 0.536, 0.804, 1.071, and 1.339% on gastric motility. The histological examination of the small intestine and a cineradiographic study of birds fed diets supplemented with lipase enzyme failed to detect any difference in gut structure, and there was no apparent adverse effect on gastric motility. Experiment 3 was conducted to test the effect of graded supplements of Pancreatic enzyme on performance of 300 male broiler chicks raised for 6 wk to determine whether the enzyme had any long-term effect on performance characteristics, especially feed intake. Only starter diets (0 to 21 d) were supplemented with 0, 0.375, 0.750, or 1.125% enzyme, and each diet was represented by three replicate pens of 25 male chicks each. Subsequent diets did not contain any enzyme. During the first 3 wk, increased dietary concentration of lipase enzyme caused a linear reduction of feed intake and body weight gain (P < 0.01). At 21 d the percentage weight of the liver was significantly greater with 1.125% enzyme (P < 0.01). However, added enzyme had no effect on 21 to 42 d or 1 to 42 d growth or feed intake (P > 0.05) or on the size of any internal organs examined at 42 d. Pancreatic enzyme has previously been shown to improve fat digestion and increase diet AMEn for young chicks fed animal-vegetable blended fats. These positive effects, however, are associated with marked anorexia, and from the present study, it seems that this effect was not related to physical changes in gut histology or in prolonged digesta transit time.

What to do when a patient with exocrine pancreatic insufficiency does not respond to pancreatic enzyme substitution, a practical guide

In the majority of patients, pancreatin microsphere preparations containing 25,000-40,000 FIP units of lipase will lead to a clinical improvement and reduction of steatorrhea in patients with exocrine pancreatic insufficiency. In patients failing to respond, the following stepwise procedure is recommended: increasing enzyme dosage; checking the patient's compliance; reevaluating the diagnosis; and as a last resort to decrease fat intake or adding H2-blockers or proton pump inhibitors. Although this stepwise procedure is time-consuming, it is necessary to prevent in patients not responding to pancreatic enzyme substitution the development of late complications of exocrine pancreatic insufficiency.

Comparison of two enteric coated microsphere preparations in the treatment of pancreatic exocrine insufficiency caused by cystic fibrosis

BACKGROUND

Pancreatic exocrine insufficiency is a common condition in patients with cystic fibrosis. Large amounts of pancreatic enzyme supplements are required to reduce malabsorption but patient compliance is not always optimal.

AIMS

To compare patients' preference and the efficacy of two enteric coated microsphere preparations in patients with cystic fibrosis.

PATIENTS

Patients with pancreatic exocrine insufficiency due to cystic fibrosis.

METHODS

Patients were assigned to the crossover treatment with Creon or Pancrease for 1 week and then to the alternative treatment. Patients had to follow a fixed diet (at least 2 g fat/kg) and had to assume 1000 units lipase/g fat. The evaluation parameters were: patients' preference, acceptance of therapy, stool fat excretion, stool weight, gastrointestinal symptoms, and tolerance.

RESULTS AND CONCLUSIONS

Of the 33/60 patients who expressed a preference for one of the two treatments, 30 preferred Creon while only 3 patients preferred Pancrease (p<0.001). No difference between the two treatments was observed regarding stool characteristics, gastrointestinal symptoms and tolerance. The mean number of capsules taken daily was reduced by 35% with Creon. The results of this study showed a preference in favour of Creon probably due to the reduction of daily capsule intake of 35%, supporting digestion as well as Pancrease.

Evaluation of dietary supplements of lipase, detergent, and crude porcine pancreas on fat utilization by young broiler chicks

The purpose of Experiment 1 was to improve the digestibility of fat through the use of supplemental lipase enzymes. A 2 x 3 factorial arrangement of treatments involving two levels of animal-vegetable blend fat (AV) (4 and 8%) and three enzyme treatments, namely none; Pancreatic, 0.714%; and Pancreatin, 0.714%, were randomly allocated within a battery brooder. There was an increase in diet ME and apparent fat digestibility when Pancreatic and Pancreatin enzymes were used (P < 0.01). However, both enzymes caused lower feed intake and lower BW gain (P < 0.01). In Experiment 2, Pancreatic enzyme was used at graded levels of 0, 0.214, 0.429, 0.643, 0.857, and 1.071%, involving 4% dietary AV fat. The ME values were greater as the enzyme level increased (P < 0.01). However, as found in Experiment 1 lower feed intake and BW gain were observed with all enzyme levels compared with the control group. There was a linear effect on feed intake and BW gain (P < 0.01) and a quadratic effect on apparent fat digestibility (P < 0.05) and feed utilization (P < 0.01). Experiment 3 was designed to test the effect of Pancreatic enzyme at 0 or 1.339% in combination with two levels of detergent, namely 0 and 10% (with 4% added AV). The detergent used consisted of a mixture of 95% Span 60 and 5% Tween 60. In general, there was no significant effect of detergent (P > 0.05). Experiment 4 was conducted to test the effect of supplementation of graded levels of ground crude porcine pancreas at 0, 0.321, 0.535, 0.750, 0.964, 1.178, or 1.392% of the diet on performance of male broiler chicks to confirm the anorexic effect caused by supplementing with Pancreatic enzyme. In general, there was no significant effect of feeding crude porcine pancreas on the performance of male broiler chicks (P > 0.05). In these studies, lipase enzymes improved fat digestion, although it is suspected that associated reduced feed intake may be associated with contaminants such as cholecystokinin hormone.

Liquid pancreatic enzyme therapy for a patient with short bowel syndrome and chronic pancreatitis in a complicated case of Crohn's disease

The case of a 45 year old female with multiple complications of Crohn's disease is reported. After multiple resections in the gastrointestinal tract she had been suffering from short bowel syndrome and severe malnutrition. With a special continuous gastric tube feeding system, she was able to maintain her weight for years. In the beginning of 1997 the enteral nutrition was not longer tolerated for an exacerbation of chronic pancreatitis. There was a weight loss, permanent pain and total parenteral nutrition had to be performed. In this situation a new liquid preparation of pancreatic enzymes which had been tested in the laboratory before, was used for continuous enzyme replacement via gastric tube. In combination with this enzyme preparation, enteral nutrition could successfully be started again.

The effect of pancreatic enzyme supplementation in patients with steatorrhoea after total gastrectomy

OBJECTIVE

To assess the influence of pancreatic enzyme supplementation on symptoms, energy intake, bowel habits, and fat malassimilation in patients after total gastrectomy.

DESIGN

A prospective, double-blind, randomized, parallel, placebo-controlled, multi-centre trial.

SETTING

Institutionalized patients in three gastroenterological rehabilitation clinics.

PARTICIPANTS

52 institutionalized patients with a faecal fat output > or = 14 g/day, operated on for malignant gastric disease a median of 198 days (interquartile range (IQR) 47-608) previously, and free from recurrence and/or metastasis.

INTERVENTIONS

Nine sachets of pancreatic enzymes per day (each containing lipase 36,000, amylase 27,000, protease 2400 FIP (Federation International Pharmaceutique)) or identical-looking placebo were given for 14 days.

MAIN OUTCOME MEASURES

Abdominal symptoms, energy intake, bowel habits and fat malassimilation.

RESULTS

After treatment, patients on enzyme therapy felt better overall (P = 0.006), but no improvement of a specific symptom could be identified. During the intervention, the median kilojoule intake per kilogram body weight was 9% higher in the placebo group (170.8 (IQR 146.9-202.6)) than in the enzyme-treated group (157.0 (IQR 134.8-170.4)) (P = 0.03). Enzyme treatment did not result in a significant difference between the placebo and the enzyme-treated group regarding bowel habits or fat malassimilation.

CONCLUSIONS

The effect of high-dose pancreatic enzymes supplementation on symptoms and steatorrhoea after total gastrectomy is marginal and does not justify its routine use.

Colonic wall thickening is related to age and not dose of high strength pancreatin microspheres in children with cystic fibrosis

OBJECTIVE

Colonic fibrosis causing stricture is a recently described complication in cystic fibrosis (CF). Studies have suggested that ultrasound evidence of bowel thickening predicts this complication and that it is prevalent among children receiving large doses of high-strength pancreatin preparations. We performed ultrasound studies on our patients to look for evidence of bowel wall thickening or early stricture.

METHOD

Detailed colonic ultrasounds were carried out in 33 children with CF including 25 who had been receiving high-strength pancreatin (Creon 25,000) continuously for 3 years at the time of study.

RESULTS

Median lipase intake was 19 330 U/kg/day (range 0-59 880 U/kg/day) and median protease intake was 387 U/kg/day (range 0-1170 U/kg/day). The combined thickness of mucosa, sub-mucosa and muscle layers was measured in ascending, transverse and descending colon using a 7.5 MHz transducer. Measurements were also made in nine healthy controls. There was no relationship between enzyme dosage and colon thickness but simple regression identified a significant relationship (P < 0.001) between age and maximum colon thickness in all three areas. The colon of CF children was up to 50% thicker than in controls.

CONCLUSIONS

Thickening of the order described elsewhere did not occur among any of the children studied. The results suggest that the most important factor determining the thickness of the CF colon is age.

Gastric emptying and intestinal transit of pancreatic enzyme supplements in cystic fibrosis

OBJECTIVE

To investigate gastric emptying and intestinal transit of pelleted pancreatin in relation to food boluses.

METHODS

Dual isotope scintigraphy combined with breath hydrogen sampling was used to track the concurrent gastric emptying and intestinal transit of 111indium labelled microspheres and a 99mtechnetium labelled tin colloid test meal. Twelve pancreatic insufficient cystic fibrosis patients aged 5 to 38 years performed the study.

RESULTS

50% gastric emptying times showed patient to patient variation. The mean discrepancy in 50% gastric emptying times between the two labels was > 67 minutes. Mean small bowel transit time for the food bolus was prolonged at 3.6 minutes. A significant correlation was seen between weight standard deviation score and 50% emptying time for pancreatin (r = +0.73).

CONCLUSION

Gastric mixing of food and pancreatin may be limited by rapid emptying of microspheres. Patients with high dosage requirements could benefit from changing the pattern of their pancreatin supplementation.

Acute lipase-induced panniculitis in rats with ligated veins of the hindlimb: a contribution to the role of acute panniculitis as a precursor of lipodermatosclerosis of venous disease

The authors studied the effect of ligation of the femoral and saphenous veins on the evolution of lipase injection-induced subcutaneous fibrosis and inflammation in the rats' hindlimbs. The superficial muscular fascia was thickened and the number of veins was increased 3 days and 3 weeks after vein ligation; both abnormalities disappeared 6 weeks postoperatively. Vein ligation did not quantitatively affect fascial thickening or fibrosing panniculitis in hindlimbs injected with lipase 6 weeks prior to sacrifice. The results contradict the proposition that lipase-induced injury of rats' subcutaneous tissues compromised by venous stasis may lead to a persistent chronic inflammation and fibrosis of the subcutaneous-fascial complex duplicating lipodermatosclerosis in man.

[Enzyme preparations in conservative treatment of chronic pancreatitis]

AIM

To study effectiveness of enzyme medicine pancitrate 25,000 in the treatment of chronic pancreatitis (CP).

MATERIALS AND METHODS

Pain, stool, creato- and steatorea, other signs of CP were examined before and after pancitrate treatment of 17 patients with chronic pancreatitis aged from 28 to 62 years.

RESULTS

Pancitrate 25,000 reduced stomach pains in 16 of 17 patients. Stool returned to normal in 8 of 13 patients. Creato- and steatorea decreased.

CONCLUSION

New dosage forms of the enzyme preparations (pancitrate 25,000, in particular) are highly effective both in deficiency of pancreatic external secretion and pain relief in exacerbation of CP.

Indomethacin and pancreatic enzymes synergistically damage intestine of rats

The use of high-dose pancreatic enzymes by patients with cystic fibrosis was associated with the development of fibrosing colonopathy. Preliminary studies indicated that the infusion of high-dose pancreatic enzymes alone did not cause intestinal damage. We hypothesized that cystic fibrosis patients that developed fibrosing colonopathy had increased intestinal permeability. Our goal was to develop a rat model for pancreatic enzyme-induced fibrosing colonopathy by increasing intestinal permeability with the use of indomethacin. Pancreatic enzymes, 150,000 units/kg/day, and indomethacin, 3 mg/kg/day, alone and in combination were administered via duodenal catheter to rats for 10 days. Indomethacin and pancreatic enzymes caused intestinal damage, resulting in significant increases in the total number of ulcers (P < 0.007), the number of severe ulcers (P < 0.003), and ulcers in the cecum and colon (P < 0.0007). We conclude that the combination of indomethacin and pancreatic enzymes acts synergistically to cause damage to the intestine.

Strategies to improve the nutritive value of rice bran in poultry diets. II. Changes in oil digestibility, metabolisable energy and attempts to increase the digestibility of the oil fraction in the diets of chickens and ducklings

1. In experiment 1, the effects of age on oil digestibility and apparent metabolisable energy (AME) were measured in chickens and ducklings between 3 and 28 d of age on a diet with 400 g rice bran/kg. In experiment 2, a biosurfactant and a food lipase were added to diets of chickens containing 200 and 400 g rice bran/kg. In experiment 3, chicken diets containing 0 or 400 g rice bran/kg were supplemented with a food lipase (2 concentrations) or a food enzyme or their combination. 2. In experiment 1, oil metabolisability and AME increased substantially as chickens aged. Oil metabolisability was much higher in ducklings, when comparisons were made with chickens of similar age. 3. In experiment 2, lipase or biosurfactant gave no improvement in bird performance. Growth rate and food conversion ratio were, respectively, 23% and 10% better on diets with 200 compared to 400 g rice bran/kg. 4. In experiment 3, there was a significant growth response to lipase plus the enzyme mixture on the diet with 200 g rice bran/kg. On the diet with 400 g rice bran/kg, growth improvement was seen with the enzyme mixture only. 5. In experiment 3, enzyme addition did not increase oil metabolisability or AME. At 4 to 8 d of age AME was higher on the diet without rice bran but oil metabolisability was the same as on the diet with rice bran. At 19 to 23 d of age AME was similar but oil metabolisability was higher on the diet with rice bran than without. Droppings' dry matter was higher on diets without than with rice bran (32.4 vs 27.1%). 6. The response to lipase and the combination of this and a food enzyme suggest that there may be benefit in examining this interaction further although they had no effect on oil metabolisability or on AME. It is concluded that a stable AME for rice bran cannot be provided for chickens until at least 21 d of age.

Effects of pancreatic enzyme preparations on erythrocyte glutathione peroxidase activities and plasma selenium concentrations in cystic fibrosis

To substitute for exocrine pancreatic insufficiency, patients with cystic fibrosis (CF) take pancreatic enzymes (PE) originating from porcine pancreas. Five different pancreatic enzyme preparations used by our patients contained 0.5-1.4 microg selenium per g tablet. In patients taking PE in doses that were gradually increased to improve fat absorption during a 48-month period, the effects of PE dose on erythrocyte selenium-dependent glutathione peroxidase (SeGSH-Px) activities and plasma selenium concentrations were studied. At baseline, erythrocyte SeGSH-Px activities were significantly lower in patients (p=.01), while plasma selenium concentrations did not differ between patients and healthy subjects. When PE dose and, consequently, selenium intake from PE was increased, erythrocyte SeGSH-Px activities (p < .001) and plasma selenium concentrations (p=.02) increased. Changes in SeGSH-Px activities during the initial 8 months correlated with those in selenium intake from PE (r=0.67, p < .001). Plasma selenium concentrations plateaued at 12 months and erythrocyte SeGSH-Px activities did so at 36 months, when patients had reached SeGSH-Px activities similar to those of healthy subjects. At 48 months, patients took an average lipase dose of 17400 U x kg(-1) x d(-1) and selenium dose from PE of 0.53 microg x kg(-1) x d(-1). We conclude that selenium content of PE preparations has a significant effect on SeGSH-Px activity in patients with CF. This form of selenium supply needs to be taken into account when selenium supplements are given to patients with CF.

The effect of intestinal permeability on pancreatic enzyme-induced enteropathy in the rat

BACKGROUND

Fibrosing colonopathy in cystic fibrosis occurs in children 2 to 7 years old and is associated with excess doses of high and regular strength lipase pancreatic enzymes, given for more than 6 months. A rat model was developed to study the effects of excessive doses of pancreatic enzymes equivalent to those producing fibrosing colonopathy in cystic fibrosis patients.

METHODS

Five groups of animals were studied after administration of different combinations of pancreatic enzymes, oleic acid, and reserpine.

RESULTS

Pancreatic enzymes alone produced minimal damage to the intestine and none to the liver. Excessive doses of pancreatic enzymes in combination with agents that increased intestinal permeability (oleic acid, reserpine) were associated with intestinal eosinophilia and necrosis of the jejunoileal muscle layer and inflammatory nodules in the liver, which increased with duration of insult.

CONCLUSIONS

Increased intestinal permeability potentiates damage to the intestine caused by excessive pancreatic enzyme dosage. It is a characteristic of cystic fibrosis that may increase vulnerability to fibrosing colonopathy.

Maintenance of growth in cystic fibrosis despite reduction in pancreatic enzyme supplementation

Twenty one children with cystic fibrosis were advised to decrease their pancreatic enzyme supplement (PES) dose to less than 10,000 units lipase/kg/day. Mean PES dosage was significantly decreased in 15 patients from 18,380 to 8647 units lipase/kg/day. There were no significant changes in energy or fat intake, but there were significant increases in weight SD score, height SD score, and weight/height ratio.

Pancreatic enzyme supplementation in cystic fibrosis patients before and after fibrosing colonopathy

BACKGROUND

In 1994 we cared for nine cystic fibrosis patients with fibrosing colonopathy. To evaluate the relationship between fibrosing colonopathy and supplemental pancreatic enzymes we reviewed our dosing of enzymes prior to fibrosing colonopathy development and then evaluated the subsequent effect of drastically reducing pancreatic enzyme dose.

METHODS

We retrospectively reviewed pancreatic enzyme dosing for 267 cystic fibrosis patients with pancreatic insufficiency. The supplemental enzyme history of nine patients with fibrosing colonopathy was contrasted with the history of 258 nonaffected patients. The pancreatic enzyme doses of 75 patients taking at least 6,000 U lipase/kg/meal were systematically reduced to approximately 2,000 lipase units/kg/meal. We evaluated the effect of this dose reduction on change in height and weight z scores one year after achievement of stable enzyme dose.

RESULTS

In the year prior to diagnosis patients with fibrosing colonopathy took a significantly larger pancreatic enzyme dose, whether assessed by highest dose or cumulative dose, than did nonaffected patients. Similar results were observed after controlling for sex and age. All 75 patients on at least 6,000 U lipase/kg/meal were able to tolerate a significant reduction in dose while achieving clinically acceptable nutrient absorption, with no change over one year in height and weight z scores.

CONCLUSIONS

Our data demonstrate a strong relationship between very high doses of pancreatic enzyme supplementation and formation of fibrosing colonopathy. These very high doses do not appear to be needed for adequate nutrient absorption and growth.

Mismatch of duodenal deliveries of dietary fat and pancreatin from enterically coated microspheres

Gastric emptying of dietary fat is affected by both chemical and physical factors; but when ingested as a free oil or an aqueous emulsion, fat may empty most rapidly immediately after the meal. In contrast, gastric transit of 1- to 3-mm spheres (like those of enterically coated pancreatins) is known to vary inversely with sphere diameter; and spheres leave the stomach initially slowly, if their diameter is > or = 1.6 mm. Our objective was to determine whether 2-mm microspheres of Pancrease would empty much more slowly than free or emulsified oil and whether 1.2-mm microspheres of Creon would empty as fast as free oil. We used a gamma camera to track the concurrent gastric emptying of 123I-labeled oil and 113mIn-labeled spheres of Pancrease or Creon in pancreatic-insufficient subjects with cystic fibrosis who ingested 20 g of free oil in spaghetti meals or 20 g of oil emulsified in a milk meal. We found that either type of oil emptied rapidly initially but slowed later, whereas either dosage form emptied slowly initially but rapidly later. Unexpectedly, the smaller spheres of Creon emptied about the same as Pancrease did after the spaghetti meal. For example, 50% of oil but < 25% of either dosage form had left the stomach by 90 min after the meals. Both dosage forms were lipophilic, forming aggregates in vitro. We concluded that the gastric emptying of either dosage form frequently lagged behind the emptying of oil from ordinary meals. We speculated that the similar transits of the 1.2-mm Creon and the 2-mm Pancrease resulted from aggregation of these microspheres in the presence of free oil.

Lack of dose-response with Pancrease MT for the treatment of exocrine pancreatic insufficiency in adults

BACKGROUND

Choosing the optimum pancreatic enzyme replacement therapy for patients with exocrine insufficiency remains a problem. An enteric coated enzyme microsphere pancreatic enzyme preparation (Pancrease) has been marketed with several levels of lipase activity, implying that there is a dose-response relationship between dose and effectiveness such that the high potency form appears to be the most cost effective.

METHODS

In a randomized, single-blind, cross-over study, we evaluated the effectiveness of a commercial enzyme preparation with different amounts of lipase per dosage unit in adults with exocrine pancreatic insufficiency. Patients received a diet comprising 100 g fat each day for 6 days. With each meal (three per day) they received two capsules of either Pancrease MT4 (8000 unit lipase), Pancrease MT10 (20,000 units lipase), Pancrease MT16 (32,000 units lipase) or placebo. A 72-h quantitative faecal collection was carried out for the last 3 days of the 6-day period.

RESULTS

There was a reduction in faecal fat excretion with each of the preparations compared to placebo. The difference failed to reach significance with the 8000 units lipase preparation (P > 0.05) but was significant (P = 0.02) with the 20,000 units lipase and the 32,000 units lipase preparations (faecal fat excretion: placebo = 42.1 +/- 29 g, lipase 8000 = 22.1 +/- 7.3 g, lipase 20,000 = 10.2 +/- 4.5 g and lipase 32,000 = 15.8 +/- 12.5 g, P < for 20,000 units and 32,000 units lipase compared to placebo).

CONCLUSION

A dose-response relationship between the amount of lipase administered with each meal and a reduction in faecal fat was not evident. The most potent preparation did not provide additional benefits compared to the less expensive lower potency dosage form.