Enzyme replacement therapy for pancreatic insufficiency: present and future

Abstract

Pancreatic enzyme replacement therapy is currently the mainstay of treatment for nutrient malabsorption secondary to pancreatic insufficiency. This treatment is safe and has few side effects. Data demonstrate efficacy in reducing steatorrhea and fat malabsorption. Effective therapy has been limited by the ability to replicate the physiologic process of enzyme delivery to the appropriate site, in general the duodenum, at the appropriate time. The challenges include enzyme destruction in the stomach, lack of adequate mixing with the chyme in the duodenum, and failing to deliver and activate at the appropriate time. Treatment is begun when clinically significant malabsorption occurs resulting in steatorrhea and weight loss. Treatment failure is addressed in a sequential fashion. Current research is aimed at studying new enzymes and delivery systems to improve the efficiency of action in the duodenum along with developing better means to monitor therapy.

Keywords: chronic pancreatitis; cystic fibrosis; exocrine pancreatic insufficiency; lipase; lipids; pancreatic enzyme replacement therapy.

Figure 1

Failure of pancreatic enzyme therapy: a systematic approach. Notes: *Restrict fat intake to 50–75 g/day, reduction in fiber, alcohol, calcium and magnesium containing antacids; **Histamine-2 receptor blockers or Proton pump inhibitors; ^†Small intestinal bacterial overgrowth, giardiasis, blind loop syndrome, malabsorption of other etiology.