Pancreatology: debunked myths
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Gubergrits, N. B., & Byelyayeva, N. V. (2020). Pancreatology: debunked myths. Herald of Pancreatic Club, 48(3), 44-53. https://doi.org/10.33149/vkp.2020.03.07

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Abstract

Enzyme replacement therapy is not always effective enough upon exocrine pancreatic insufficiency. One of the main reasons is myths — doctors’ misconceptions about the indications and rules of replacement therapy.

In particular, there is an outdated opinion about the effectiveness of tablet enzyme preparations used for the relief of pancreatic pain. However, a number of evidence-based studies have proved that enzyme preparations are not effective enough to relieve pain in chronic pancreatitis, and thus should not be used for this purpose. This statement is recorded in the United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis, as well as in the recommendations of the American College of Gastroenterology. In addition, tablet preparations are characterized by asynchronism of the passage of the chyme and the tablet along the digestive tract.

The second myth is that drugs without an acid-resistant coat start hydrolyzing the components of the chyme in the stomach, which ensures higher efficiency as compared to Creon. But in the absence of a coat, enzymes are inactivated in the acidic environment of the stomach and cannot have any effect at all.

The third myth is that enzyme preparations always cause constipation. In fact, constipation occurs in no more than 10% of cases. They are usually associated with an overdose of the drug, concomitant pathology or insufficient compliance.

The fourth myth is that prescribing the doses of enzyme preparations indicated in the European Guidelines causes addiction. It is crucial to know that such doses do not exceed 10% of the pancreas’s own capacities, therefore, they cannot significantly affect these capabilities, which is also demonstrated by evidence-based studies.

The fifth myth is that patients gain weight because of enzyme preparations, and they should not be prescribed upon overweight and obesity. Numerous data firmly show that pancreatic insufficiency often occurs in such cases, and enzyme preparations are required.

The sixth myth is that a drug with a different composition can be produced under the usual established product name. For example, NEO is added to the name to “mask” a drug with a new composition. Doctors should carefully monitor the composition of such drugs.

The seventh myth is that a minimicrospherical preparation (Creon) is as effective as microspherical preparation. However, this statement turned out to be a myth as well. Minimicrospherical preparations are proved to be significantly more effective in clinical practice.

Thus, the above-mentioned myths, like many others, are based on insufficient knowledge in the field of pancreatology.

https://doi.org/10.33149/vkp.2020.03.07
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References

1. Бєляєва Н. В. Оптимізація діагностики і лікування хронічного біліарного панкреатиту у хворих з ожирінням: автореф. дис. ... канд. мед. наук: 14.01.02. ДЗ «Луган. держ. мед. ун-т». Луганськ, 2011. 24 с.
2. Бондаренко О. А. Патогенез, клініка, діагностика та лікування хронічного панкреатиту у хворих на ожиріння з інсулінорезистентністю: автореф. дис. ... д-ра мед. наук: 14.01.02. Львівський національний медичний університет ім. Д. Галицького. Тернопіль, 2015. 42 с.
3. Губергриц Н. Б. Нравственные проблемы панкреатологии в Украине. Сучасна гастроентерологія. 2007. № 2. С. 80–86.
4. Губергриц Н. Б., Беляева Н. В., Клочков А. Е., Фоменко П. Г. Хронический панкреатит: работа над ошибками. Сучасна гастроентерологія. 2015. №3. С. 58–65.
5. Ивашкин В. Т., Маев И. В., Охлобыстин А. В., Алексеенко С. А., Белобородова Е. В., Кучерявый Ю. А. и др. Клинические рекомендации Российской гастроэнтерологической ассоциации по диагностике и лечению экзокринной недостаточности поджелудочной железы. Рос. журн. гастроэнтерол., гепатол., колопроктол. 2018. № 28(2). С. 72–100.
6. Ивашкин В. Т., Маев И. В., Шифрин О. С. и др. Рекомендации Российской гастроэнтерологической ассоциации по диагностике и лечению хронического панкреатита (Проект). Рос. журн. гастроэнтерол., гепатол., колопроктол. 2013. № 1. С. 66–87.
7. Інструкція для медичного застосування лікарського засобу Фестал® НЕО 10 000. Наказ МОЗ України №2249 від 30.11.2018. Державний реєстр лікарських засобів України. URL: http://www.drlz.com.ua/ibp/ddsite.nsf/all/shlz1?opendocument&stype=4EB54D63DD84FB95C225835B002EDB42 (дата просмотра: 08.05.2020).
8. Коротько Г. Ф. Физиология системы пищеварения. Краснодар: Группа Б, 2009. 607 с.
9. Кучерявый Ю. В., Смирнов А. В., Джаватханова Р. Т., Устинова Н. Н. Механизмы боли при хроническом панкреатите: что и кому назначить практикующему врачу? Фарматека. 2013. № 14. С. 21–27.
10. Пахомова И. Г. Дифференцированный подход к противоболевой терапии при хроническом панкреатите. Consilium medicum. Гастроэнтерология. 2013. № 1. С. 32–35.
11. Щекина М. И., Панчук М. С. Применение панкреатических энзимов в лечении болевой формы хронического панкреатита с умеренной внешнесекреторной недостаточностью. Мед. совет. 2013. № 10. С. 81–88.
12. Adams D. B., et al. Pancreatitis: medical and surgical management. Chichester: Wiley Blackwell. 2017. 326 p.
13. Beger H. G., ed. The pancreas: an integrated textbook of basic science, medicine and surgery. Oxford: Willey Blackwell, 2018. 1173 p.
14. Brown A., Hughes M., Tenner S., Banks P. A. Does pancreatic enzyme supplementation reduce pain in patients with chronic pancreatitis? A meta-analysis. Am. J. Gastroenterol. 1997. Vol. 92. P. 2032–2035.
15. Bruno M. J. Exocrine pancreatic insufficiency: efficacy of enzyme replacement therapy. Amsterdam: Thesis Publishers, 1995. 167 p.
16. Code C. F., Schlegel J. F. The gastrointestinal interdigestive housekeeper: Motor correlates of the interdigestive myoelectric complex of the dog. Proc. 4th Int. Symp. on GI Motility. Daniel E. E. (ed.) Vancouver: Mitchell Press, 1973. P. 631–634.
17. de la Iglesia-García D., Huang W., Szatmary P., Baston-Rey I., Gonzalez-Lopez J., Prada-Ramallal G., Mukherjee R., Nunes Q. M., Domínguez-Muñoz J. E., Sutton R. Efficacy of pancreatic enzyme replacement therapy in chronic pancreatitis: systematic review and meta-analysis. Gut. 2017. Vol. 66, No 8. P. 1354–1355.
18. de-Madaria E., Abad-González Á., Aparicio J. R. et al. Recommendations of the Spanish Pancreatic Club on the diagnosis and treatment of chronic pancreatitis: part 2 (treatment). Gastroenterol. Hepatol. 2013. Vol. 36, No 6. P. 422–436.
19. Dervenis C. G. (ed.) Advances in pancreatic disease: molecular biology, diagnosis and treatment. Stuttgart et al., 1996. 401 p.
20. Dominguez-Muñoz J. E. Management of pancreatic exocrine insufficiency. Curr. Opin. Gastroenterol. 2019. Vol. 35, No 5. P. 455–459.
21. Domínguez-Muñoz J. E., Phillips M. Nutritional therapy in chronic pancreatitis. Gastroenterol. Clin. North Am. 2018. Vol. 47, No 1. P. 95–106.
22. Duggan S. N., Smyth N. D., O’Sullivan M., Feehan S., Ridgway P. F., Conlon K. C. Nutr. Clin. Pract. The prevalence of malnutrition and fat-soluble vitamin deficiencies in chronic pancreatitis. 2014. Vol. 29, No 3. P. 348–354.
23. Friess H., Kleeff J., Malfertheiner P., Müller M. W., Homuth K., Büchler M. W. Influence of high-dose pancreatic enzyme treatment on pancreatic function in healthy volunteers. Int. J. Pancreatol. 1998. Vol. 23, No 2. P. 115–123.
24. Frulloni L., Falconi M., Gabbrielli A. et al. Italian consensus guidelines for chronic pancreatitis. Dig. Liver Dis. 2010. Vol. 42, Suppl. 6. P. 381–406.
25. Gardner T. B., Adler D. G., Forsmark C. E., Sauer B. G., Taylor J. R., Whitcomb D. C. ACG Clinical Guideline: Chronic Pancreatitis. Am. J. Gastroenterol. 2020. Vol. 115, No 3. P. 322–339.
26. Gardner T. B., Smith K. D. Pancreatology: a clinical casebook. Cham (Switzerland): Springer International Publishing AG, 2017. 193 p.
27. Goebell H., Klotz U., Nehlsen B., Layer P. Oroileal transit of slow release 5-ASA. Gut. 1993. Vol. 34. P. 669–675.
28. Graham D. Y. Enzyme replacement therapy of exocrine pancreatic insufficiency in men. Relation between in vitro enzyme activities and in vivo potency in commercial pancreatic extracts. N. Engl. J. Med. 1977. Vol. 296. P. 1316–1317.
29. Gubergrits N. B., Byelyayeva N. V., Lukashevich G. M., Fomenko P. G. Diagnostic value of bioelectrical impedance analysis (BIA) in chronic pancreatitis (CP). Pancreatology. 2016. Vol. 16, No 3S1. P. S37.
30. Holtmann G., Kelly D. G., Sternby B., DiMagno E. P. Survival of human pancreatic enzymes during small bowel transit: effect of nutrients, bile acids, and enzymes. Am. J. Physiol. 1997. Vol. 273, No 2, Pt 1. P. G553–558.
31. Ihse I., Lilja P., Lundquist I. Intestinal concentrations of pancreatic enzymes following pancreatic replacement therapy. Scand. J. Gastroenterol. 1980. Vol. 15. P. 137–144.
32. Isakson G., Ihse I. Pain reduction by an oral pancreatic enzyme preparation on chronic pancreatitis. Dig. Dis. Sci. 1983. Vol. 28. P. 97–102.
33. Keller J., Layer P. Human pancreatic exocrine response to nutrients in health and disease. Gut. 2005. Vol. 54. Suppl. 6. P. vi1–28.
34. Kuhnelt P., Mundlos S., Adler G. Einflub der Pelletgrobe eines Pankreasenzympraparates auf die duodenale lipolytische Aktivitat (The size of enteric-coated microspheres influences theintraduodenal lipolytic activity). J. Gastroenterol. 1991. Vol. 29. P. 417–421.
35. Layer P., Go V. L., DiMagno E. P. Fate of pancreatic enzymes during small intestinal aboral transit in humans. Am. J. Physiol. Vol. 251, No 4, Pt 1. P. G475–480.
36. Lieb J. G. 2nd, Forsmark C. E. Review article: pain and chronic pancreatitis. Aliment. Pharmacol. Ther. 2009. Vol.29, No 7. P. 706–719.
37. Löhr J. M., Dominguez-Munoz E., Rosendahl J., Besselink M., Mayerle J., Lerch M. M., Haas S., Akisik F., Kartalis N., Iglesias-Garcia J., Keller J., Boermeester M., Werner J., Dumonceau J. M., Fockens P., Drewes A., Ceyhan G., Lindkvist B., Drenth J., Ewald N., Hardt P., de Madaria E., Witt H., Schneider A., Manfredi R., Brøndum F. J., Rudolf S., Bollen T., Bruno M.; HaPanEU/UEG Working Group. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). United European Gastroenterol. J. 2017. Vol. 5, No 2. P. 153–199.
38. Löhr J.-M., Oliver M. R., Frulloni L. Synopsis of recent guidelines on pancreatic exocrine insufficiency. UEG Journal. 2013. Vol. 1, No 2. P. 79–83.
39. Meyer J. H., Elashoff J., Porter-Fink V. et al. Human postprandial gastric emptying of 1−3 millimeterspheres. Gastroenterology. 1988. Vol. 94. P. 1315−1325.
40. Meyer J. The ins and outs of oral pancreatic enzymes. N. Engl. J. Med. 1977. Vol. 296. P. 1347–1348.
41. Mundlos S., Kuhnelt P., Adler G. Monitoring enzyme replacement treatment in exocrine pancreatic insufficiency using the cholesteryl breath test. Gut. 1991. Vol. 31. P. 1324–1328.
42. Olesen S. S., Büyükuslu A., Køhler M., Rasmussen H. H., Drewes A. M. Sarcopenia associates with increased hospitalization rates and reduced survival in patients with chronic pancreatitis. Pancreatology. 2019. Vol. 19, No 2. P. 245–251.
43. Sablin O., Butenko E. Enzyme preparations in gastroenterology. Farmindex. 2000. Vol. 3. P. 44–53.
44. Schlegel J. F., Code C. F. The gastric peristalsis of the interdigestive housekeeper. Proc. 5th Int. Symp. on GI Motility. Vantrappen G. (ed.) Leuven: Typoff Press, 1975. P. 3211.
45. Shafiq N., Rana S., Bhasin D. et al. Pancreatic enzymes for chronic pancreatitis. Cochrane Database Syst. Rev. 2009. Vol. 4. CD006302.
46. Somaraju U. R., Solis-Moya A. Pancreatic enzyme replacement therapy for people with cystic fibrosis. Cochrane Database Syst. Rev. 2016. Vol. 11. CD008227.
47. Treatment of pain in chronic pancreatitis: AGA medical position statement. Gastroenterology. 1998. Vol. 115. P. 763–764.
48. Żuk K., Czkwianianc E., Degowska M. et al. Zalecenia diagnostyczne I terapeutyczne w przewlekłym zapaleniu trzustki. Rekomendacje Grupy Roboczej Konsultanta Krajowego w dziedzinie Gastroenterologii i Polskiego Klubu Trzustkowego. Przegląd Gastroenterol. 2011. Vol. 6, No 6. P. 339–352.