Exocrine Pancreatic Insufficiency: Seen but Not Recognized?

David A. Johnson, MD


May 21, 2014

In This Article

Treatment of Pancreatic Insufficiency

When you make the diagnosis of chronic pancreatitis or pancreatic insufficiency, how is it managed?

The primary treatment is supplemental lipase, particularly the oral pancreatic lipase products. There are 6 products now on the commercial market in the United States, 5 of which are enteric-coated. That is particularly important because lipase, which is given orally, is subject to degradation by acid. If you use Viokase® (pancrelipase), which is not enteric-coated, you must also give a proton pump inhibitor or it will be degraded.

In fact, proton pump inhibitors may be helpful even with the enteric-coated products, especially if your patient is not responding well. If you reduce the acidity in the gastric juices and raise the pH, this might result in earlier release of the enteric coating, which may in fact put the pancreatic lipase in contact with the food in a more proximal location to facilitate better absorption. This is a trick to use if you are not seeing good results with an enteric-coated product.

Capsules should not be chewed. The granules should be protected with the enteric coating, but patients can open the capsules and put the granules on applesauce or yogurt if they prefer. I typically instruct patients to take this right before a meal and to take a capsule toward the end of the meal. The idea is to better balance the enzyme exposure throughout the meal. It is the contact time that allows the best absorptive capability.

Dosing of Pancreatic Lipase

Pancreatic lipase is dosed in units. The pancreas normally secretes up to 900,000 units of lipase with a meal, and you only need 10%.

The starting dose for the standard patient is 500 units/kg/dose, and this dose can be upregulated to approximately 2500 units/kg/dose.

In pediatric patients, high doses (6000 units/kg/dose) have been associated with a complication known as fibrosing colonopathy. Be careful if you are increasing the dose.

If you are not getting the response that you think you should have, make sure that you have good compliance, but also think about other things. Think about celiac disease and bacterial overgrowth, which also may be seen in patients with exocrine insufficiency.


I have provided some overview for treating pancreatic insufficiency.

Follow-up should assess the patient's response to treatment, including evaluating biochemical parameters, the response to vitamin and mineral supplementation, nutritional parameters (pre-albumin, carotene, and serum albumin, which can lag in response), overall physical health, and diarrhea and stool patterns.

Hopefully this has given you an overview for your next patient with chronic exocrine pancreatic insufficiency. It is important to remember that dosing units are targets, beginning at 500 units/kg per dose. Don't forget that exocrine pancreatic insufficiency mimics celiac disease and bacterial overgrowth, and have a heightened awareness in these patients. Use the fecal elastase test in patients who are not responding to conventional evaluations for diarrhea.

I'm Dr. David Johnson. Thanks for listening.


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