59 Pancreas Enzyme Replacement Dosing Before and After Total Pancreatectomy and Islet Autotransplantation

Abstract

INTRODUCTION: Pancreas enzyme replacement therapy (PERT) is used to improve nutrient digestion, especially of lipids, in patients with exocrine pancreas insufficiency who otherwise may experience maldigestion, malabsorption, malnutrition, and steatorrhea. Although underdosage of PERT is common, adequate dosing is particularly important in patients who undergo total pancreatectomy and islet autotransplantation (TPIAT). Current PERT dosing guidelines do not explicitly provide recommendations following TPIAT so we determined the adequacy of PERT dosing in a cohort of patients with TPIAT. METHODS: The TPIAT database from 2009-2018 was searched to determine PERT dosing in subjects before TPIAT (n = 14), immediately after TPIAT and at 6 and 12 months (n = 11). Adequate weight based dosing was established using Cystic Fibrosis Foundation guidelines. Average PERT dose was calculated and the ranges were reported, P < 0.05 was significant. RESULTS: Data was available in 14 patients, and 6 and 12 month data was available in 11 patients. Indication for TPIAT included 6 idiopathic chronic pancreatitis (CP), 4 genetic CP (4 PRSS1, 1 CFTR), 3 idiopathic recurrent AP, 1 alcohol induced CP. 3 patients were not using PERT before TPIAT, 7 were underdosed (average 62,000 U/day, range 6,000–108,000), and 4 were adequate (205,250 U/day; 125,000–228,000). At discharge 9 patients were underdosed (72,222 U/day; 6000–108,000), and 5 were adequate (248,200 U/day; 125,000–360,000). At 6 months 3/11 pts (27%) were underdosed (56,666 U/day; 30,000–80,000) and 8/11 pts (73%) were adequate (228,000 U/day; 144,000–432,000). At 12 months 2/11 pts (18%) were underdosed (108,000 U/day each) and 9/11 (82%) pts were adequate (430,222 U/day; 144,000–384,000). PERT dose increase was significant for the period post-TPIAT to 6 months (P = 0.04). The graph shows the trend of PERT during the study period. CONCLUSION: Underdosing of PERT was common before and immediately after TPIAT. It is possible that poor oral intake dictated the immediate low post TPIAT dose. Significant PERT dose increase was noted in the first 6 months, and was sustained at 12 months. PERT dosing needs to be monitored closely and weight based dosing should be considered to achieve optimal nutritional benefit.