Use Of Pancreatic Enzyme Replacement Therapy Research Articles

Implementation of Best Practices in Pancreatic Cancer Care in the Netherlands: A Stepped-Wedge Randomized Clinical Trial.

Implementation of new cancer treatment strategies as recommended by evidence-based guidelines is often slow and suboptimal. To improve the implementation of guideline-based best practices in the Netherlands in pancreatic cancer care and assess the impact on survival. This multicenter, stepped-wedge cluster randomized trial compared enhanced implementation of best practices with usual care in consecutive patients with all stages of pancreatic cancer. It took place from May 22, 2018 through July 9, 2020. Data were analyzed from April 1, 2022, through February 1, 2023. It included all patients in the Netherlands with pathologically or clinically diagnosed pancreatic ductal adenocarcinoma. This study reports 1-year follow-up (or shorter in case of deceased patients). The 5 best practices included optimal use of perioperative chemotherapy, palliative chemotherapy, pancreatic enzyme replacement therapy (PERT), referral to a dietician, and use of metal stents in patients with biliary obstruction. A 6-week implementation period was completed, in a randomized order, in all 17 Dutch networks for pancreatic cancer care. The primary outcome was 1-year survival. Secondary outcomes included adherence to best practices and quality of life (European Organisation for Research and Treatment of Cancer [EORTC] global health score). Overall, 5887 patients with pancreatic cancer (median age, 72.0 [IQR, 64.0-79.0] years; 50% female) were enrolled, 2641 before and 2939 after implementation of best practices (307 during wash-in period). One-year survival was 24% vs 23% (hazard ratio, 0.98, 95% CI, 0.88-1.08). There was no difference in the use of neoadjuvant chemotherapy (11% vs 11%), adjuvant chemotherapy (48% vs 51%), and referral to a dietician (59% vs 63%), while the use of palliative chemotherapy (24% vs 30%; odds ratio [OR], 1.38; 95% CI, 1.10-1.74), PERT (34% vs 45%; OR, 1.64; 95% CI, 1.28-2.11), and metal biliary stents increased (74% vs 83%; OR, 1.78; 95% CI, 1.13-2.80). The EORTC global health score did not improve (area under the curve, 43.9 vs 42.8; median difference, -1.09, 95% CI, -3.05 to 0.94). In this randomized clinical trial, implementation of 5 best practices in pancreatic cancer care did not improve 1-year survival and quality of life. The finding that most patients received no tumor-directed treatment paired with the poor survival highlights the need for more personalized treatment options. ClinicalTrials.gov Identifier: NCT03513705.

OGC P22 The Prevalence of Malabsorption and Use of Pancreatic Enzyme Replacement Therapy Post Upper GI Surgery

Abstract Background Pancreatic enzyme insuffiency (PEI) appears to be under recognised and under treated in upper GI surgery due to limited evidence regarding the prevalence of PEI post operatively. This has potential to exacerbate the risk of malnutrition in an already vulnerable patient group. Pancreatic enzyme replacement therapy (PERT) may influence nutritional status and quality of life after Upper GI surgery, but the research to date remains controversial. A retrospective audit was carried out to review the use of PERT in 233 Upper GI surgeries across a two-year period. Methods Retrospective audit documenting all patients that have undergone a GIST resection, distal gastrectomy, subtotal gastrectomy, completion gastrectomy, oesophagectomy and total gastrectomy between 2021-2022 at a tertiary centre for Upper GI cancer surgery. It was recorded from electronic patient records which of these patients were commenced on PERT post operatively. The time frame in which the PERT was initiated was captured, as well as and what dose patients required to provide symptom relief. The duration of PERT prescription was recorded in addition to patients’ tolerance. Results Initiation of PERT varied from one month to one year after surgery, with most patients (n=24) commencing PERT within the first month. The final dosage of PERT required varied between 50,000iu (n=36) and 125,000iu (n=6). Many patients remain on PERT (n=53); whilst 26% of individuals stopped PERT within six months due to no benefit found or poor tolerance (n=19). Conclusions The use of PERT in one third of surgical Upper GI patients highlights the prevalence of PEI in this patient group. This data indicates the initiation of PERT is higher within the first three months following surgery, with the majority of these patients’ requiring PERT for long term use. A larger, multicentre trial is needed to further analyse the benefits of PERT on weight and quality of life, whilst addressing the potential influence of confounding variables such as disease stage and adjuvant treatment.

Incidence of fibrosing colonopathy with pancreatic enzyme replacement therapy in patients with cystic fibrosis

BackgroundHigh daily doses of pancreatic enzyme replacement therapy (PERT) were historically associated with risk of fibrosing colonopathy (FC) in people with cystic fibrosis (pwCF), leading to development of PERT dosing guidelines and reformulated products. This study quantified incidence of FC in pwCF treated with PERT following those measures. MethodsThis large prospective cohort study included eligible pwCF enrolled in the Cystic Fibrosis Foundation Patient Registry with ≥1 clinic visit in 2012–2014 and follow-up through 2020. Data on PERT exposure, demographics, and medical history were collected. Clinical data, imaging, and histopathology of suspected cases were examined by an independent adjudication panel of physicians familiar with this complication. ResultsBase Study Population included 26,025 pwCF who contributed 155,814 person-years [mean (SD) 6.0 (2.0) years] of follow-up. Over 7.8 years, 29 pwCF had suspected FC; three cases were confirmed by adjudication, 22 cases were confirmed as not FC, and four cases were indeterminate. There were 22,161 pwCF exposed to any PERT, with mean PERT use time of 5.583 person-years and mean daily dose of 8328 U lipase per kg per day. All three confirmed cases and four indeterminate cases of FC occurred during current use of PERT. Incidence rates per 1000 person-years exposed were 0.0242 (95 % CI [0.0050, 0.0709]) for confirmed FC and 0.0566 (95 % CI [0.0227, 0.1166]) for indeterminate or confirmed FC. ConclusionsThe incidence of FC in pwCF is very low in the era of current treatment guidelines and more stringent quality standards for PERT products.

Dietary therapy for patients with chronic pancreatitis in Japan: a cross-sectional online survey of physicians and registered dietitians.

This study was aimed towards understanding the current status of dietary therapy for patients with pancreatic exocrine insufficiency (PEI) in Japan and its alignment with Japanese recommendations for high-fat intake and concomitant high-potency pancreatic enzyme replacement therapy (PERT) by surveying treating physicians and registered dietitians. The 19-item physicians' online questionnaire collected data about the number of patients with PEI treated, methods used to assess PEI and nutritional status in patients with PEI, as well as provision of dietary guidance and details of treatment with PERT. The 10-item registered dietitians' online questionnaire captured data about the provision of dietary guidance, including setting (inpatient or outpatient) and details of nutritional guidance provided to patients. Overall, 35 physicians and 23 dietitians completed the respective questionnaires. The primary cause of PEI in patients treated by physicians during the previous month was chronic pancreatitis (80.5%). Of 30 (86%) physicians who reported implementing dietary guidance for patients with PEI, less than half (43%) followed national guidelines and most (83%) implemented a low-fat diet. The use of PERT in recently treated patients with PEI was low. Amongst 11 (48%) dietitians who reported providing dietary guidance to patients with chronic pancreatitis and PEI, 7 (64%) recommended restricting fat intake in patients with uncompensated chronic pancreatitis. Dietitians overall were more likely to provide guidance about alcohol avoidance (91%) than smoking cessation (48%) to appropriate patients. This survey suggests that additional educational efforts are required to align the management practices of physicians and registered dietitians with evidence-based clinical practice guidelines for Japanese patients with chronic pancreatitis and PEI.

Nationwide implementation of best practices in pancreatic cancer care (PACAP-1): Stepped-wedge cluster randomized trial.

4152 Background: Implementation of new treatment strategies in cancer care is often inadequate and slow. We aimed to implement best practices in pancreatic cancer care using a nationwide stepped wedge design and assess the impact on overall survival. Methods: Nationwide multicenter stepped-wedge cluster randomized controlled trial comparing implementation of best practices with usual care (May 22, 2018 – May 29, 2020). Best practices included adequate use of perioperative and palliative chemotherapy, pancreatic enzyme replacement therapy (PERT), and metal biliary stents. The 6-week implementation period in all 17 Dutch pancreatic centers and their regional referral networks included monitoring, return visits, and provider feedback in combination with education and reminders. Primary outcome was one-year overall survival for all disease stages and secondary outcomes included guideline compliance and quality of life. Results: Overall, 5580 patients diagnosed with pancreatic cancer were included; 2939 after implementation of best practices versus 2641 before. One-year survival did not differ among the groups (HR 0.98, 95 CI 0.88-1.08). Overall use of perioperative chemotherapy (neoadjuvant and adjuvant) did not significantly differ, but use of palliative chemotherapy significantly increased (23.9% to 30.3%, OR 1.38, 95 CI 1.10-1.74). Also the use of PERT (34.2% to 45.2%, OR 1.64, 95 CI 1.28-2.11); and metal biliary stents (74.1.% to 83.3%, OR 1.78, 95 CI 1.13-2.08) significantly increased. The Global Health Score did not differ (AUC 43.8 to 42.7, median difference -1.12, 95 CI -3.13-0.80, n=655). Conclusions: This nationwide population-based trial to enhance implementation of best practices in pancreatic cancer care showed successful implementation of most best practices, but no increase in one-year survival and quality of life. Clinical trial information: NCT03513705 .

Prescription patterns of pancreatic enzyme replacement therapy for patients with pancreatic cancer in the United States.

Exocrine pancreatic insufficiency (EPI) is frequently seen in patients with pancreatic cancer (PDAC) and is thought to contribute to nutritional complications. While EPI can be pharmacologically temporized with pancreatic enzyme replacement therapy (PERT), there is lack of clear evidence informing its use in PDAC. Here we aim to survey pancreatic surgeons regarding their utilization of PERT in the management of EPI for PDAC. An online survey was distributed to the members of The Americas Hepato-Pancreato-Biliary Association (AHPBA) and The Pancreas Club. 86.5% (180/208) of surgeons prescribe PERT for at least some resectable/borderline resectable PDAC cases. Only a minority of surgeons order investigations to confirm EPI before starting PERT (28.1%) or test for adequacy of therapy (28.3%). Few surgeons believe that PERT has an effect on overall survival (19.7%) or disease-free survival (6.25%) in PDAC. PERT is widely prescribed in patients with resectable/borderline resectable PDAC, but investigations establishing EPI and assessing PERT adequacy are underutilized. A substantial proportion of surgeons are unclear as to the effect of PERT on survival outcomes in PDAC. These data call for prospective studies to establish guidelines for optimal use of PERT and its effects on survival outcomes in PDAC.

The Impact of Pancreatic Enzyme Replacement Therapy on Patients With Advanced Pancreatic Adenocarcinoma: A Systematic Review and Narrative Synthesis.

Advanced pancreatic cancer has a poor prognosis globally. Patients often develop pancreatic exocrine insufficiency leading to malabsorption. This systematic literature review explores the impact of pancreatic enzyme replacement therapy (PERT) on patients with advanced pancreatic cancer. Data sources include MEDLINE, CINAHL, Embase, Cochrane (CENTRAL), PsychINFO, and Joanna Briggs Institute databases from inception to January 14, 2022, with reference list checking on Google Scholar. Narrative synthesis was used as the eligible studies were likely to be heterogeneous and hard to compare. This synthesis approach uses 4 steps: theory development, preliminary synthesis, exploration of relationships, and assessment of the robustness of the synthesis. Four themes arose from analyzing the study outcomes including PERT education, efficacy of PERT, the patient experience, and lack of awareness regarding enzyme replacement. The included studies did not use validated tools or standardized measurements, which made it difficult to compare or draw conclusions. Pancreatic enzyme replacement therapy shows the potential to improve symptoms, nutrition, weight loss, and survival, but high-quality studies with standardized outcomes have not been completed. Patient and health professional education is required because there seems to be a general lack of awareness about the use of PERT in pancreatic cancer.Systematic Review Registration: PROSPERO 2020 CRD42020195986.

Correlates of Pancreatic Enzyme Replacement Therapy Intake in Adults with Cystic Fibrosis: Results of a Cross-Sectional Study.

Most people with cystic fibrosis (pwCF) develop pancreatic insufficiency and are treated with pancreatic enzyme replacement therapy (PERT). We aimed to describe the use of PERT and assess the correlates of PERT dose in adult pwCF. In a cross-sectional study at the Copenhagen CF Centre, the participants reported PERT intake, gastrointestinal (GI) symptoms and the use of concomitant treatments. Demographic and clinical characteristics were extracted from the Danish CF Registry. We used linear regression to assess the correlates of PERT dose per kg bodyweight (U-lipase/kg). We included 120 pwCF with a median age of 32.9 years, 46% women and 72% F508delta homozygote. The PERT dose ranged from 0 to 6160 U-lipase/kg per main meal (mean 1828; SD 1115). The PERT dose was associated with participants’ sex (men vs. women: 661; 95% CI: 302; 1020 U-lipase/kg), age (−16; 95% CI: −31; −1 U-lipase/kg per year) and weight (−45; 95% CI: −58; −31 U-lipase/kg per kg). Having less frequent constipation and being lung transplanted were also associated with a higher PERT dose. A third of participants did not take PERT for snacks, and this was associated with the frequency of diarrhoea. These findings indicate that PERT intake may be improved to reduce GI symptoms.

P-O18 Pancreatic Enzyme Replacement Therapy in Upper GI Surgery- A Retrospective Audit

Abstract Background Pancreatic enzyme insufficiency (PEI) appears to be under recognised and under treated in upper GI surgery due to limited clinical data regarding the prevalence of PEI after gastric surgery, therefore potentially leading to malnutrition in an already vulnerable patient group. This retrospective audit looked at a total of 197 resections in a two year time period and aimed to determine what type of upper GI surgery pancreatic enzyme replacement therapy (PERT) was used in, if use of PERT improved malabsorption symptoms and/or nutritional markers (weight and grip strength) and finally if there was a consistent PERT dosage that was prescribed with good effect. Methods Retrospective audit recorded all patients that had undergone a total gastrectomy, subtotal gastrectomy, oesophagectomy, colonic interposition, palliative bypass and GIST resections between 2018-2019 that were undertaken in a regional centre for upper GI cancer surgery. Through means of patient electronic records it was recorded which of these patients started on PERT and if there was any improvement in their symptoms. Nutritional markers were recorded at specific intervals and the final dosage of PERT used with good effect. Results 66.6% of total gastrectomies were commenced on PERT with 68.1% reporting an improvement in symptoms and 27.2% reporting some improvement. 34.7% of subtotal gastrectomies were commenced on PERT and 100% of these patients experienced symptomatic relief. 22.4% of oesophagectomies were commenced on PERT with 68% reporting an improvement in symptoms and 9% some improvement. 33% of the colonic interpositions were commenced on PERT with 100% of patients reporting an improvement with symptoms. PEI was not identified in palliative bypass or GIST surgery. No significant improvement in weight was seen 9-12 months post-operatively in patients who began Creon 0-3 months after their operation, with a p-value of 0.19. Not enough grip strength data was available to analyse. The average final PERT dosage in patients that reported some improvement to improvement in symptoms was 50,000 – 75,000 units with every meal and snack. Conclusions More prevalent usage of PERT seen in total gastrectomy resections with good effect. This finding would benefit from further higher quality research to determine the mechanism behind this to support wider PERT usage in this patient group. In view of the overall positive outcomes in regards to symptom control across gastrectomies and oesophagectomies, albeit in small numbers, it should be a considered treatment and regularly screened for. In order to get a statistically significant result in regards to weight improvement when commenced on PERT a bigger sample size would be needed

P-P10 The survival benefit of pancreatic enzyme replacement therapy in adult patients undergoing treatment of pancreatic neuroendocrine tumours

Abstract Background Patients with pancreatic neuroendocrine tumours (pNETs), treated with somatostatin analogues (SSAs) or pancreaticoduodenectomy, are at risk of exocrine pancreatic insufficiency. This is frequently undiagnosed but can be treated with pancreatic enzyme replacement therapy (PERT). PERT improves survival and nutritional status in other exocrine pancreatic insufficiency-associated conditions such as pancreatic adenocarcinoma. This single-centre retrospective cohort study aimed to establish whether PERT increases survival or weight maintenance in SSA or pancreaticoduodenectomy-treated patients with pNETs. Methods Departmental databases identified patients (n = 82) diagnosed with pNETs between 2009 and 2019 and managed with SSAs and/or pancreaticoduodenectomy. Their baseline characteristics, treatments and outcomes were established from clinical records. Cases (n = 47) received PERT 3 months after either pancreaticoduodenectomy or commencement of SSAs, controls (n = 35) did not. Overall survival was analysed using the Kaplan-Meier method, the log-rank test and multivariable Cox regression. Percentage monthly weight changes were compared using the Mann-Witney U test. The cohort was investigated as a whole and stratified by intervention (pancreaticoduodenectomy or SSAs) as more cases having undergone pancreaticoduodenectomy was a potential confounder. Results Median survival was not reached in either group. Cases experienced significantly greater 5-year overall survival (81% vs 53%, p = 0.010), however, PERT was not independently associated with survival (Hazard ratio 0.47, 95% CI 0.17-1.30, p = 0.143). Cases showed superior median weight maintenance (+0.04% vs -0.10% per month, p = 0.013), but had lower mean baseline weights (70.0kg vs 81.9kg, p = 0.003). Considering SSA-treated patients (n = 55) only, cases (n = 27) showed greater median weight maintenance (+0.04% vs -0.21% per month, p = 0.025) and a trend towards improved median overall survival (55.5, 95% CI 10.3-100.7 vs 47.7, 95% CI 19.1-76.4 months, p = 0.054). Conclusions PERT may improve the maintenance of weight and therefore nutrition in patients with pNETs, treated with SSAs or pancreaticoduodenectomy. PERT may also convey a survival benefit in this same population, however, due to the numerous factors which affect survival, this study appears underpowered to reliably explore this outcome. Further studies are required to accurately define the use and benefits of PERT in this population.

S44 Analysis of Real World Patient Experience With Pancreatic Enzyme Replacement Therapy (PERT) in the Treatment of Exocrine Pancreatic Insufficiency (EPI)

Introduction: PERT is the standard of care treatment for EPI. Real-world data on patient experience with PERT is lacking. The aim of this patient survey was to assess patient understanding and their use of PERT. Methods: An IRB-approved survey of 75 members of Inspire’s Pancreatic Cancer and Pancreatitis Support communities (inspire.com) was conducted. Eligibility included having EPI secondary to chronic pancreatitis (CP), pancreatic cancer (PC), pancreatic surgery (PS), or acute pancreatitis (AP), and current or past PERT experience. 76% were male, 85% white, 56% age 50-69 yrs, 56% living in a large city/ suburb. 67% reported CP, 19% PC, 5% PS (non-CP/PC), 9% AP (no concomitant CP). PERT was prescribed by gastroenterologist/pancreatologist in 64%; oncologist 17%; surgeon 11%; others 8%. Results: 28% of respondents felt their physician did not provide detailed information about EPI and 31% did not get an explanation about how PERT works. 83% searched for EPI information mainly online. HCP counseling on need for chronic PERT use was reported in 67% of those on PERT (n=60) and 27% in those no longer on PERT (n=15). In the latter group, no patient took PERT for more than 5 years despite CP/PC history. 11% reported receiving no instructions on how and when to take PERT; 21% were instructed to take PERT with food or meals and no instructions for snacks, and 21% reported not taking PERT with any snacks. 59% were instructed to take PERT solely before or after eating and 56% were taking it as such. 36% reported PERT doses< 40,000 LU/meal. 10-15% did not understand how many capsules to take per meals or snacks. 24% decreased dosage mainly because they felt there will be no health consequences. 21% reported purposely skipping PERT mostly because they felt that PERT was not needed with every meal/snack. Patients stopped PERT mainly due to pill burden. 39% reported absence of follow-up by their physician on how they are doing since start of PERT. 84% of those with physician follow-up were asked about their EPI symptoms. Conclusion: Up to 1/3 of participants reported gaps in patient-physician dialogue regarding how to use PERT. More than half took PERT solely before or after eating. 36% of patients were underdosed (based on ACG Guidelines for CP). ∼ 1/4 skipped PERT or decreased the dose. Targeted education interventions are warranted to improve barriers to care and sequelae of untreated/undertreated EPI.

The use of pancreatic enzyme replacement therapy in patients with a diagnosis of chronic pancreatitis and pancreatic cancer in the US is infrequent and inconsistent.

Patients with chronic pancreatitis or pancreatic cancer commonly develop exocrine pancreatic insufficiency, and may not be adequately treated with pancreatic enzyme replacement therapy (PERT). To estimate the frequency of diagnostic testing for exocrine insufficiency, and appropriate use of PERT, in a commercially insured population in the US. We utilised a nationally representative administrative database representing 48.67 million individuals in over 80 US healthcare plans to assess testing for and treatment of exocrine insufficiency in patients who received a diagnosis of chronic pancreatitis (n=37061) or pancreatic cancer (n=32461) from 2001to 2013. We identified the details of any testing for exocrine insufficiency and PERT use. We defined appropriate PERT use as a dosage of ≥120000 USP units of lipase daily. Multiple logistic regression was used to identify predictors of appropriate use of PERT. In patients with chronic pancreatitis, 6.5% had any testing for exocrine insufficiency, 30.4% filled a prescription for PERT, and 8.5% were prescribed an adequate dose. In those with pancreatic cancer, 1.9% had testing for exocrine insufficiency, 21.9% filled a prescription for PERT, and 5.5% were prescribed an adequate dose. Number of comorbidities, testing for exocrine insufficiency, pancreatic surgery and duration of enrolment were independent predictors for use and appropriate dosing. Testing for exocrine insufficiency, and appropriate dosing of PERT in patients with chronic pancreatitis or pancreatic cancer, is infrequent and inconsistent in an insured US population. Efforts are needed to educate medical providers on the best practices for managing exocrine pancreatic insufficiency in these patients.

Perioperative pancreatic enzyme replacement therapy reduces morbidity in patients undergoing pancreatoduodenectomy

Introduction: Exocrine pancreatic insufficiency (EPI) is a common entity in patients scheduled for pancreatoduodenectomy due to obstruction of the pancreatic duct. The treatment for EPI is pancreatic enzyme replacement therapy (PERT) but this is not routinely prescribed in patients undergoing PD. The aim of this study was to examine the effects of perioperative PERT on the incidence of postoperative pancreatic fistula (POPF) and surgical site infections (SSI) in patients undergoing PD. Materials & Methods: Patients undergoing PD during the period January 2014 to December 2017 were maintained database. The electronic medical record was reviewed to determine the presence of symptoms indicative of EPI and the use of PERT during the pre- and post-operative periods. The presence of a dilated pancreatic duct was ascertained through review of pre-operative cross-sectional imaging. Patients were divided into 3 groups: patients who received preoperative PERT continued into the postoperative period (Preop PERT); patients who received only postoperative PERT (Postop PERT); and patients who did not receive PERT (No PERT). A POPF was defined according to the International Study Group of Pancreatic Fistula and classified as biochemical leaks (A) or clinically significant (B or C). SSIs were classified as superficial, deep, and organ-space. The incidence of SSI and POPF were compared between groups. Results: Of 327 patients who underwent a PD, 239 (73%) had evidence of EPI, with a dilated pancreatic duct identified in 203 (62.0%) and symptoms of EPI in 142 (43.4%). The Results are summarized in Table 1. Conclusion: Patients who received preoperative PERT had lower rates of POPF both overall and clinically relevant POPF compared to those receiving postoperative PERT or no PERT. The preop PERT group also experienced less SSIs. Routine preoperative use of PERT should be considered in patients undergoing PD.

Frequency of Appropriate Use of Pancreatic Enzyme Replacement Therapy and Symptomatic Response in Pancreatic Cancer Patients.

Pancreatic cancer (PC) and its treatments can result in pancreatic exocrine insufficiency that requires pancreatic enzyme replacement therapy (PERT). Appropriate PERT usage is during meals and snacks. The aim was to determine the frequency of appropriate use of PERT and its impact on symptom alleviation in PC through a patient-reported outcomes online platform. Users in the Pancreatic Cancer Action Network's Patient Registry were prompted to answer a standalone questionnaire about their experience with PERT. Two hundred sixty-two users completed the PERT questionnaire (January 2016-January 2018). Patients who reported taking PERT with meals had higher alleviation of symptoms compared with those taking PERT prior to or after meals. Specifically, "feeling of indigestion," "light-colored or orange stools," and "visible food particles in stool" were significantly decreased. Patients taking PERT with meals reported weight gain and less weight loss. Of the 89% of PC patients prescribed PERT, 65% were prescribed PERT appropriately with all meals and snacks. Overall compliance with PERT administration guidelines was low (50% [105/208]). Improvement in symptoms significantly correlated with appropriate use of PERT. Increase in PC patient and provider education about appropriate PERT usage and administration is warranted.

Diagnosis and management of pancreatic exocrine insufficiency.

In 2015, the Australasian Pancreatic Club (APC) published the Australasian guidelines for the management of pancreatic exocrine insufficiency (http://pancreas.org.au/2016/01/pancreatic-exocrine-insufficiency-guidelines). Pancreatic exocrine insufficiency (PEI) occurs when normal digestion cannot be sustained due to insufficient pancreatic digestive enzyme activity. This may be related to a breakdown, at any point, in the pancreatic digestive chain: pancreatic stimulation; synthesis, release or transportation of pancreatic enzymes; or synchronisation of secretions to mix with ingested food. Main recommendations: The guidelines provide advice on diagnosis and management of PEI, noting the following: A high prevalence of PEI is seen in certain diseases and conditions, such as cystic fibrosis, acute and chronic pancreatitis, pancreatic cancer and pancreatic surgery. The main symptoms of PEI are steatorrhoea or diarrhoea, abdominal pain, bloating and weight loss. These symptoms are non-specific and often go undetected and untreated. PEI diagnosis is predominantly based on clinical findings and the presence of underlying disease. The likelihood of PEI in suspected patients has been categorised into three groups: definite, possible and unlikely. If left untreated, PEI may lead to complications related to fat malabsorption and malnutrition, and have an impact on quality of life. Pancreatic enzyme replacement therapy (PERT) remains the mainstay of PEI treatment with the recommended adult initial enzyme dose being 25 000-40 000 units of lipase per meal, titrating up to a maximum of 75 000-80 000 units of lipase per meal. Adjunct acid-suppressing therapy may be useful when patients still experience symptoms of PEI on high dose PERT. Nutritional management by an experienced dietitian is essential. Changes in management as a result of these guidelines: These are the first guidelines to classify PEI as being definite, possible or unlikely, and provide a diagnostic algorithm to facilitate the early diagnosis of PEI and appropriate use of PERT.

Chronic pancreatitis.

Chronic pancreatitis describes a wide spectrum of fibro-inflammatory disorders of the exocrine pancreas that includes calcifying, obstructive, and steroid-responsive forms. Use of the term chronic pancreatitis without qualification generally refers to calcifying chronic pancreatitis. Epidemiology is poorly defined, but incidence worldwide seems to be on the rise. Smoking, drinking alcohol, and genetic predisposition are the major risk factors for chronic calcifying pancreatitis. In this Seminar, we discuss the clinical features, diagnosis, and management of chronic calcifying pancreatitis, focusing on pain management, the role of endoscopic and surgical intervention, and the use of pancreatic enzyme-replacement therapy. Management of patients is often challenging and necessitates a multidisciplinary approach.

PWE-217 Pancreatic enzyme replacement therapy in chronic pancreatitis and pancreatic cancer – are we getting it right?: Abstract PWE-217 Table 1

<h3>Introduction</h3> Pancreatic enzyme insufficiency (PEI) is a well recognised cause of malnutrition in chronic pancreatitis and pancreatic cancer. Pancreatic enzyme replacement therapy (PERT) in the form of enteric coated pancreatin microspheres is recommended in both these groups of patients with symptoms of PEI to prevent weight loss and malnutrition and improve quality of life. Given that the probability of PEI is high in PC (80–90%), PERT is recommended without the use of formal diagnostic tests. The optimal starting dose of PERT is 40–50000 lipase units per main meal. The aim of this study was to evaluate the use of PERT including appropriate dosing in chronic pancreatitis (CP) and pancreatic cancer (PC) and to ascertain if there was a difference in prescribing practice between these groups. <h3>Method</h3> A single centre retrospective analysis of patients diagnosed with CP and PC since 2010 in a large North London district general hospital was performed using local upper gastrointestinal cancer multidisciplinary team records and clinical coding. We identified 149 patients with PC and 110 with CP though 32 patients from the PC group and 4 from CP were excluded from the study due to poor documentation in the records leading to insufficient information surrounding enzyme supplementation and dosages. Information was collected from electronic patient records on the patients’ symptoms, evidence of PERT and the dose prescribed. <h3>Results</h3> Symptoms of pancreatic enzyme insufficiency (abdominal pain, weight loss or steatorrhoea) were recorded in 72/117 (61.5%) of PC patients compared with 75/106 (70.8%) of CP patients. PERT was prescribed in 14/72 (19.5%) patients with PC versus 53/75 (70.7%) with CP. The Table 1shows the enzyme formulation and dosages used in both groups. <h3>Conclusion</h3> In our study we demonstrate that the majority of patients with PEI in CP are prescribed PERT, a stark contrast with a mere 20% in PC. However in both groups, most patients were not prescribed optimal doses of PERT though again, this figure was better in the CP group (14/53 or 26.4%) compared to the PC group (2/14 or 14.3%). This study highlights the missed opportunity to reduce symptoms and improve quality of life in CP and PC patients with a simple intervention. Increased awareness of the availability and appropriate dosing of PERT in conditions resulting in PEI is required. <h3>Disclosure of interest</h3> None Declared.

PWE-206 Pancreatic enzyme replacement therapy in pancreatic cancer- a role for the dietician

<h3>Introduction</h3> Pancreatic enzyme insufficiency (PEI) is a well-recognised cause of malnutrition in pancreatic cancer (PC). Pancreatic enzyme replacement therapy (PERT) in the form of enteric coated pancreatin microspheres is recommended in these patients with symptoms of PEI to prevent weight loss and malnutrition and improve quality of life. Given that the probability of PEI is high in PC (80–90%), PERT is recommended without the use of formal diagnostic tests. The optimal starting dose of PERT is 40–50000 lipase units per main meal. The aim of this study was to evaluate the use of PERT in PC patients, to ascertain if these patients were given the appropriate PERT dose and to determine whether dietician review was associated with more and better PERT use. <h3>Method</h3> A single centre retrospective analysis of patients diagnosed with PC in 2014 in a tertiary hospital specialising in the treatment of patients with hepato-pancreato-biliary (HPB) diseases. We identified 80 patients with PC. Information was collected from electronic patient records regarding the patients’ symptoms of PEI, evidence of PERT use, the dose prescribed and whether the patients were seen by a dietician. Fisher’s exact test was used to calculate whether (a) dietician review was associated with higher rate of PERT use and (b) dietician review was associated with higher rate of appropriate PERT dosing. <h3>Results</h3> Symptoms of PEI (abdominal pain, weight loss or steatorrhoea) were recorded in 57.5% of PC patients (46/80). PERT was prescribed in the minority of patients [41.3% (33/80)] with appropriate dosing given to the majority of patients when prescribed [66.7% (22/33)]. A dietician was involved in the care of less than half [43.8% (35/80)] of patients. However, referral to a dietician was strongly associated with PERT use with 60% (21/35) of patients being referred given PERT compared to only 26.7% (12/45) of patients who were not (p = 0.003). Dietician involvement was also associated with more appropriate PERT use with 85% (17/20) of patients given appropriate doses compared to 45.5% (5/11); (p = 0.038) when started without dietician review. <h3>Conclusion</h3> In this audit, we demonstrated that while symptoms of PEI were present in the majority of patients, the minority of patients were given PERT. The minority of patients were seen by a dietician but when assessed were more likely to receive PERT at the appropriate dosage, which may account for the low rate of PERT in the cohort as a whole. This study highlights the lack of awareness of the problem of PEI in PC patients amongst managing physicians. This could lead to a missed opportunity to reduce symptoms and improve quality of life in patients with a simple intervention. A referral to the dietician was shown to benefit these patients. <h3>Disclosure of interest</h3> None Declared.

Su1888 Pancreatic Enzyme Replacement Therapy in Chronic Pancreatitis and Pancreatic Cancer- Are We Getting It Right?

Introduction Pancreatic enzyme insufficiency (PEI) is a well recognised cause of malnutrition in chronic pancreatitis and pancreatic cancer. Pancreatic enzyme replacement therapy (PERT) in the form of enteric coated pancreatin microspheres is recommended in both these groups of patients with symptoms of PEI to prevent weight loss and malnutrition and improve quality of life. Given that the probability of PEI is high in PC (80–90%), PERT is recommended without the use of formal diagnostic tests. The optimal starting dose of PERT is 40–50000 lipase units per main meal. The aim of this study was to evaluate the use of PERT including appropriate dosing in chronic pancreatitis (CP) and pancreatic cancer (PC) and to ascertain if there was a difference in prescribing practice between these groups. Method A single centre retrospective analysis of patients diagnosed with CP and PC since 2010 in a large North London district general hospital was performed using local upper gastrointestinal cancer multidisciplinary team records and clinical coding. We identified 149 patients with PC and 110 with CP though 32 patients from the PC group and 4 from CP were excluded from the study due to poor documentation in the records leading to insufficient information surrounding enzyme supplementation and dosages. Information was collected from electronic patient records on the patients’ symptoms, evidence of PERT and the dose prescribed. Results Symptoms of pancreatic enzyme insufficiency (abdominal pain, weight loss or steatorrhoea) were recorded in 72/117 (61.5%) of PC patients compared with 75/106 (70.8%) of CP patients. PERT was prescribed in 14/72 (19.5%) patients with PC versus 53/75 (70.7%) with CP. The Table 1shows the enzyme formulation and dosages used in both groups. Conclusion In our study we demonstrate that the majority of patients with PEI in CP are prescribed PERT, a stark contrast with a mere 20% in PC. However in both groups, most patients were not prescribed optimal doses of PERT though again, this figure was better in the CP group (14/53 or 26.4%) compared to the PC group (2/14 or 14.3%). This study highlights the missed opportunity to reduce symptoms and improve quality of life in CP and PC patients with a simple intervention. Increased awareness of the availability and appropriate dosing of PERT in conditions resulting in PEI is required. Disclosure of interest None Declared.

Pancreatic enzyme replacement therapy (PERT) for malabsorption in patients with metastatic pancreatic cancer

PurposeThe diagnosis of metastatic pancreatic cancer (PC) carries a poor prognosis. PC is associated with weight loss and malabsorption in high rates secondary to pancreatic exocrine insufficiency. UK and USA...