Treatment Options for Exocrine Pancreatic Insufficiency

Exocrine pancreatic insufficiency (EPI) is a condition that develops when the pancreas does not make or fail to release sufficient digestive enzymes. In people with exocrine pancreatic insufficiency, the undigested food gets left behind in the intestines only. This can cause abdominal pain, diarrhea, and bloating. In severe cases, exocrine pancreatic insufficiency can also cause fatty loose stools, along with weight loss from malnutrition. There is no cure for Exocrine pancreatic insufficiency, but your doctor will work together with you to find treatment options that can help manage your symptoms of Exocrine pancreatic insufficiency and improve the overall quality of life. Here are some of the treatment options for exocrine pancreatic insufficiency.

What is Exocrine Pancreatic Insufficiency?

Exocrine pancreatic insufficiency (EPI) is a medical condition in which the pancreas fails to make or release sufficient digestive enzymes.(1,2,3,4) This causes the undigested food to be left in the intestines. This can lead to abdominal pain, bloating, and diarrhea. In cases of severe exocrine pancreatic insufficiency, a person may also experience loose and fatty stools, along with significant weight loss due to malnutrition. There are numerous conditions that can cause exocrine pancreatic insufficiency. These include:

Treatment Options for Exocrine Pancreatic Insufficiency

There is no cure for exocrine pancreatic insufficiency. Your doctor is likely to recommend that you carry out certain dietary and lifestyle modifications to relieve your symptoms, regardless of what is the underlying cause of the condition. If you have severe exocrine pancreatic insufficiency, or you have recently had digestive tract surgery, your doctor may prescribe enzymes to help replace the ones that your pancreas produce naturally. Your doctor will also work together with you to find the best possible treatment that can help alleviate your symptoms, treat the underlying condition that is causing the symptoms of exocrine pancreatic insufficiency and also improve the overall quality of your life.

Treating Exocrine Pancreatic Insufficiency with Medications

Here are the commonly used medications that can help in treating exocrine pancreatic insufficiency:

1. Prescription Drugs For Exocrine Pancreatic Insufficiency

The pancreas naturally releases digestive enzymes like lipase, amylase, and protease in the small intestine. The body needs all these enzymes for proper digestion. However, in people with exocrine pancreatic insufficiency, the pancreas does not produce enough of these enzymes. In such cases, people may benefit from pancreatic enzyme replacement therapy (PERT). (10)

Pancreatic enzyme replacement therapy can replace these enzymes and also help you absorb the nutrients from the foods you eat. Your doctor decides on the actual dosage depending on the severity of your condition and symptoms.(11)

You will be advised to take the medications at the beginning of every snack or meal you have, but these medicines should never be taken on an empty stomach. Your dietitian or doctor will explain when and how to take these medications. In order for these drugs to be effective, they must be taken precisely as your doctor has prescribed.(12)

It is common for some people to experience heartburn or acid reflux while being on pancreatic enzyme replacement therapy. To combat this, your doctor may also add a proton pump inhibitor (PPI) that will help decrease the amount of stomach acid.(13)

Proton pump inhibitors are medications that work by lowering the amount level of acid the glands of the stomach lining manufacture. However, not everyone who is on pancreatic enzyme replacement therapy needs to take proton pump inhibitors.

2. Over-the-Counter Medications For Exocrine Pancreatic Insufficiency

In cases where the symptoms are mild, or you only feel mild heartburn due to your condition, then you might not be in need of taking prescription-strength medications or proton pump inhibitors. These drugs are readily available over-the-counter under brand names like Prevacid (lansoprazole) and Nexium (esomeprazole).

Your doctor or gastroenterologist may also recommend other over-the-counter products but in a certain dosage. You can also ask your pharmacist for recommendations on medications for heartburn.

There are also some types of pancreatic enzyme replacement supplements that are available over-the-counter without a prescription. However, since these supplements vary in potency and consistency, it is always better to consult your doctor before you start taking these supplements. If you have exocrine pancreatic insufficiency, it is best to avoid taking over-the-counter pancreatic enzyme replacement supplements. And definitely do not take them without talking to your doctor. Your doctor will also be able to determine if the particular supplement is correct for your condition.

Your doctor may prescribe pancreatic enzyme replacement therapy if they feel you require these medications, but you will need to strictly follow the prescription of your doctor while taking them.

Treating Exocrine Pancreatic Insufficiency with Dietary Changes

Earlier, doctors used to treat exocrine pancreatic insufficiency by recommending a low-fat diet.(14) Nowadays, low-fat diets are no longer advised by doctors as such a diet can actually worsen the weight loss due to malnutrition, which is typically associated with this medical condition. A low-fat diet also makes it more challenging for the body to properly absorb the vitamins that are dissolved in fat. Instead of a low-fat diet, your doctor will recommend that you consume healthy fats like:

  • Fatty fish like salmon, mackerel, tuna, trout, herring, and sardines
  • Flaxseed
  • walnuts
  • Soybean and safflower oil
  • Soymilk
  • Tofu
  • Sesame, sunflower, and pumpkin seeds
  • Peanut butter
  • Nuts like peanuts, almonds, hazelnuts, pecans, cashews, and macadamia
  • Olives
  • Avocados
  • Olive, peanut, canola, and sesame oils

At the same time, you should avoid consuming highly processed and hard-to-digest foods, particularly foods that contain large quantities of animal fat or hydrogenated oils. Consuming too much fiber is also not recommended as this can make it difficult for your digestive system. Instead of three heavy meals, eating smaller but more frequent meals can make it easier for your stomach to break down the proteins and fats.

Since everyone is different and experiences the symptoms of exocrine pancreatic insufficiency differently, it may take you some time to find the best diet that works for you. Consulting a dietitian can also help you learn more about how to plan a healthy and affordable meal and snacks that will alleviate your symptoms.

Since exocrine pancreatic insufficiency interferes with the natural ability of the body to absorb nutrients from the food, it can lead to malnutrition. This can also impact your intake of fat-soluble vitamins like vitamin A, E, D, and K. To combat this, you may need to take dietary supplements. However, if you are on pancreatic enzyme replacement therapy, then you will continue to get all the required nutrients from your diet itself without needing to take any supplements.

Furthermore, it is essential to know that certain dietary supplements can interfere with your prescription or over-the-counter medications. Your doctor can also recommend that you take some very specific vitamins and minerals in precise dosage as needed.

It is necessary to talk to your doctor before taking any type of dietary supplements.(15)

Treating Exocrine Pancreatic Insufficiency with Lifestyle Changes

Your doctor will also recommend that you make certain lifestyle modifications to alleviate the symptoms of exocrine pancreatic insufficiency. Here are some lifestyle changes you can incorporate to improve the quality of your life:

  • Avoid taking alcohol: Alcohol can harm the pancreas, especially if you are a heavy or regular drinker. If you are finding it difficult to avoid alcohol, you should talk to your doctor about how you can quit alcohol in a safe manner.(16)
  • Quit smoking: Smoking is linked with various pancreatic conditions like pancreatic cancer and pancreatitis. If you smoke, you should take the help of your doctor to quit smoking. There are many smoking cessation programs that can help you quit smoking in a controlled manner.(17)
  • Eat a healthy diet: Consuming a well-balanced and nutritious diet based on what your doctor or dietitian has recommended will help you get relief from your symptoms.
  • Regular exercise: Regular physical activity is essential for your overall health. However, it is best to ask your doctor about which exercises are the best for you before you begin exercising.
  • Reduce your stress levels: While it is impossible to remove stress entirely from your life, you can learn ways to better cope with your stress. Deep breathing exercises, meditation, tai chi, and yoga are some activities that can help.

Conclusion

Around half of the people who are treated with enzyme replacement therapy do not experience a full return to normal digestion of fat. This usually happens for a couple of reasons, including low dosage or not taking the enzyme replacements correctly.(18) An overgrowth of bacteria in the intestines or acid imbalances in the stomach can also prevent enzyme replacement therapy from working.

If your treatment is not working correctly, your doctor may change your treatment plan. This could include an increase in your enzyme dosage, the addition of proton pump inhibitors, and also add on a treatment for bacterial overgrowth in the intestines.

If there is still no improvement in your symptoms, your doctor may then also evaluate you for another underlying condition apart from exocrine pancreatic insufficiency.

References:

  1. Domínguez‐Muñoz, J.E., 2011. Pancreatic exocrine insufficiency: diagnosis and treatment. Journal of gastroenterology and hepatology, 26, pp.12-16.
  2. Struyvenberg, M.R., Martin, C.R. and Freedman, S.D., 2017. Practical guide to exocrine pancreatic insufficiency–breaking the myths. BMC medicine, 15(1), pp.1-8.
  3. Struyvenberg, M.R., Martin, C.R. and Freedman, S.D., 2017. Practical guide to exocrine pancreatic insufficiency–breaking the myths. BMC medicine, 15(1), pp.1-8.
  4. Singh, V.K., Haupt, M.E., Geller, D.E., Hall, J.A. and Diez, P.M.Q., 2017. Less common etiologies of exocrine pancreatic insufficiency. World Journal of Gastroenterology, 23(39), p.7059.
  5. Hardt, P.D., Hauenschild, A., Nalop, J., Marzeion, A.M., Jaeger, C., Teichmann, J., Bretzel, R.G., Hollenhorst, M. and Kloer, H.U., 2003. High prevalence of exocrine pancreatic insufficiency in diabetes mellitus. Pancreatology, 3(5), pp.395-402.
  6. Seibold, F., Scheurlen, M., Müller, A., Jenss, H. and Weber, P., 1996. Impaired pancreatic function in patients with Crohn’s disease with and without pancreatic autoantibodies. Journal of clinical gastroenterology, 22(3), pp.202-206.
  7. Kristidis, P., Bozon, D., Corey, M., Markiewicz, D., Rommens, J., Tsui, L.C. and Durie, P., 1992. Genetic determination of exocrine pancreatic function in cystic fibrosis. American journal of human genetics, 50(6), p.1178.
  8. DiMagno, M.J., 2018. Exocrine pancreatic insufficiency and pancreatitis associated with celiac disease. Pancreapedia: The Exocrine Pancreas Knowledge Base.
  9. Leeds, J.S., Hopper, A.D., Sidhu, R., Simmonette, A., Azadbakht, N., Hoggard, N., Morley, S. and Sanders, D.S., 2010. Some patients with irritable bowel syndrome may have exocrine pancreatic insufficiency. Clinical Gastroenterology and Hepatology, 8(5), pp.433-438.
  10. Peter, L., Jutta, K. and Lankisch, P.G., 2001. Pancreatic enzyme replacement therapy. Current gastroenterology reports, 3(2), pp.101-108.
  11. Sikkens, E.C., Cahen, D.L., Kuipers, E.J. and Bruno, M.J., 2010. Pancreatic enzyme replacement therapy in chronic pancreatitis. Best practice & research Clinical gastroenterology, 24(3), pp.337-347.
  12. Fieker, A., Philpott, J. and Armand, M., 2011. Enzyme replacement therapy for pancreatic insufficiency: present and future. Clinical and Experimental Gastroenterology, 4, p.55.
  13. Domínguez‐Muñoz, J.E., 2009. Pancreatic enzyme replacement therapy: exocrine pancreatic insufficiency after gastrointestinal surgery. HPB, 11, pp.3-6.
  14. Lindkvist, B., 2013. Diagnosis and treatment of pancreatic exocrine insufficiency. World journal of gastroenterology: WJG, 19(42), p.7258.
  15. Imrie, C.W., Connett, G., Hall, R.I. and Charnley, R.M., 2010. Enzyme supplementation in cystic fibrosis, chronic pancreatitis, pancreatic and periampullary cancer. Alimentary pharmacology & therapeutics, 32, pp.1-25.
  16. Gullo, L., Barbara, L. and Labò, G., 1988. Effect of cessation of alcohol use on the course of pancreatic dysfunction in alcoholic pancreatitis. Gastroenterology, 95(4), pp.1063-1068.
  17. Luaces-Regueira, M., Iglesias-García, J., Lindkvist, B., Castiñeira-Alvariño, M., Nieto-García, L., Lariño-Noia, J. and Domínguez-Muñoz, J.E., 2014. Smoking as a risk factor for complications in chronic pancreatitis. Pancreas, 43(2), pp.275-280.
  18. Lindkvist, B., 2013. Diagnosis and treatment of pancreatic exocrine insufficiency. World journal of gastroenterology: WJG, 19(42), p.7258.

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