Latest news with #pancreaticinsufficiency
Medscape
6 days ago
- Health
- Medscape
Rapid Review: Exocrine Pancreatic Insufficiency (EPI)
While historically underdiagnosed, increased awareness and improved diagnostic strategies for exocrine pancreatic insufficiency (EPI) have helped identify patients earlier, thus facilitating more effective management. However, despite advances in treatment modalities, patient outcomes vary considerably due to differences in individual physiology, adherence to treatment regimens, and concurrent health issues. Efforts to address these disparities focus increasingly on personalized medicine, emphasizing the integration of tailored nutritional strategies, patient education, and multidisciplinary care teams to improve patient outcomes comprehensively. Recent guidelines advocate for the prompt initiation of PERT as soon as EPI is diagnosed. Additionally, a multidisciplinary evaluation to assess further nutritional needs and coordination with endocrinologists for the evaluation and treatment of diabetes is also warranted. Untreated EPI can impair growth in pediatric patients, and is associated with a number of clinical symptoms including gastrointestinal effects, osteoporosis, sarcopenia, coagulopathy, neuropathy, and other sequelae related to nutrient deficiency. Although other tests can help in certain cases, EPI can be sufficiently diagnosed with a validated pancreatic function test, and awaiting further confirmatory information such as severe clinical symptoms, positive imaging findings, or documented nutritional deficiencies is not necessary. Learn more about management approaches for EPI. Digestion of fat is a central function of the pancreas, with dysfunction causing deficiency in fat soluble essential vitamins. Although the American Gastroenterological Association (AGA) guidelines recommend a low-to-moderate-fat diet for patients with EPI, they specifically recommend against a very-low fat diet as this can exacerbate deficiencies. Further, meals should be more frequent and smaller, and vitamin and mineral deficiencies should be screened for at diagnosis and annually thereafter. Learn more about diet in EPI. Although fecal fat testing is considered the gold-standard for assessing fecal fat malabsorption, which is a measure of pancreatic dysfunction, it has low specificity for EPI since other diseases can present with steatorrhea. The AGA notes that fecal fat testing is 'rarely needed', it is burdensome (requires a 72 hour stool collection), and can only be done when the patient is on a high-fat diet. Additionally, fecal fat tests are known to be susceptible to false positive results in patients with diarrhea, which is a common symptom of EPI. The AGA recommends fecal elastase as the best test for initial screening, although fecal fat may be useful in cases with inconclusive clinical features and imaging. Learn more about pancreatic function tests. The AGA Clinical Practice Update emphasizes that while cross-sectional imaging — such as CT, MRI, and endoscopic ultrasound — cannot directly diagnose EPI, it plays an essential role in identifying benign and malignant pancreatic diseases that may underlie or contribute to exocrine insufficiency. Imaging can reveal features like advanced calcific chronic pancreatitis, ductal changes, or significant pancreatic atrophy, which correlate with the presence of EPI. However, moderate changes in imaging do not reliably correlate with EPI, and normal imaging is associated with its absence. Although advanced tools like secretin-enhanced MRCP or elastography show promise, current imaging lacks sufficient accuracy to predict EPI on its own. Therefore, imaging should be viewed as a complementary tool in the diagnostic process, providing context about pancreatic structure rather than functional status. For dosing of PERT, the AGA has specific recommendations dependent on fat content of meals and current symptom profile, not imaging findings. Learn more about the multidisciplinary workup for patients with EPI. The latest AGA guidelines emphasize the importance of regular and comprehensive monitoring of nutritional status in all patients with EPI, including regular DEXA scans every 1-2 years. Additionally, baseline and periodic assessment of anthropometric indicators, biochemical markers, and clinical evaluation should be established. DEXA scanning can help to detect sarcopenia, which is possible even in patients with obesity. It can be caused by the nutritional deficits seen in patients with EPI and is associated with increased adverse outcomes and physical disability. The AGA also notes that other muscle mass and function tests can be considered as well. Learn more about the management of patients with EPI.
Medscape
02-06-2025
- Business
- Medscape
UK Pharmacies Struggle with Severe Creon Shortage
Nearly all UK pharmacies are experiencing severe 'challenges' supplying pancreatic enzyme replacement therapy (PERT), the National Pharmacy Association (NPA) warned. A sample survey by the association found that 96% of pharmacies were struggling to obtain Creon (pancrelipase, Mylan). A further 89% reported difficulties supplying PERT alternatives. Patients Resorting to Extreme Measures The ongoing shortage has forced patients to take desperate action, according to the NPA, which said some are rationing existing medication supplies or skipping meals entirely. One pharmacist described it as the 'worst stock shortage' they had ever encountered. Patients report eating only one meal daily, contacting multiple pharmacies for supplies, or travelling more than 30 miles to obtain the medication. Critical Medication for Serious Conditions Creon is used to treat pancreatic exocrine insufficiency from a variety of causes, including pancreatic cancer, cystic fibrosis, and pancreatitis. The medication, derived from porcine pancreatin, contains lipase, protease, and amylase. It dissolves rapidly in the stomach to release its enzyme load in the small intestine, where its lipolytic, amylolytic, and proteolytic activity enable absorption of the products of pancreatic digestion. PERT medications need to be taken to facilitate digestion every time a patient eats. In clinical trials, treatment with Creon markedly improved stool consistency, abdominal pain, and stool frequency, independent of the underlying disease. The consequences of inadequate dosing can be severe. Patients may become too unwell for surgery, struggle with chemotherapy tolerance, or experience debilitating symptoms that diminish quality of life. Symptoms may include diarrhoea, flatulence, bloating, abdominal pain, unexplained weight loss, and oily, foul-smelling stools (steatorrhoea). Safety Concerns Olivier Picard, NPA chair, warned the shortage has 'profound effects' on patients who depend on the medication to survive and lead normal lives. 'It simply cannot be right that in the 21st century patients are skipping meals in order to ration their medication,' he said. Last week, the government extended the current Serious Shortage Protocol (SSP) for Creon until 21 November 2025. The protocol allows pharmacists to use professional judgement to decide whether it's 'reasonable and appropriate' to substitute a patient's prescription for an alternative agent for one dispensing month. It allows pharmacies to supply a reduced quantity of Creon capsules that might be in stock, without having to send a patient back to their GP to get a new prescription. Two SSPs for Creon 10,000 and 25,000 capsules have been in place since May 2024. However, the survey found that 81% of pharmacies felt the current arrangements for managing the shortage were inadequate. In particular, pharmacists were still obliged to refer patients back to prescribers when seeking PERT alternatives. Alternative PERT formulations Nutrizym and Pancrex are also now in short supply as manufacturers struggle to meet demand. GPs and pharmacies can order unlicensed Creon or other PERT products from overseas, but other countries have experienced similar shortages. Calls for Regulatory Change The NPA and Pancreatic Cancer UK issued a joint statement urging government action. They called for a national plan to address shortages and support patients with alternative care. Picard said that although the situation was complex and not the fault of the government, medicine shortages were all too common. 'Highly trained pharmacists should also be permitted to use their professional judgment to supply alternative medicines — where it is safe and appropriate — in the event of the prescribed version being unavailable.' Alfie Bailey-Bearfield, head of influencing and health improvement at Pancreatic Cancer UK, said that the findings were 'deeply worrying'. It was 'totally unacceptable' that cancer patients were still taking desperate measures that put their health, wellbeing, and eligibility for treatment at risk, when the charity had been raising concerns with Department of Health and Social Care (DHSC) officials and PERT suppliers for more than a year. 'This crisis continues to put people's health on the line, and they cannot afford to wait any longer,' he said. A DHSC spokesperson said that the supply issues with Creon were European-wide and caused by limited availability of raw ingredients along with manufacturing capacity constraints. 'We are working closely with industry and the NHS to mitigate the impact on patients and resolve the issues as quickly as possible,' the spokesperson said.
