Trip Answers

Question answered:21/05/08

In answering this question, we do not know the age or sex of the patient concerned or the cause of pancreatic insufficiency. This is a highly specific question and one for which we found no diagnostic or management algorithm to help answer it.

 

However, we did locate some general information that may be of some relevance.

 

The PatientPlus web site contains an article on the diagnosis of chronic pancreatitis in which it notes:

 

“Chronic pancreatitis is the result of chronic inflammation of the pancreas which results in irreversible damage to the pancreas. It is associated with severe abdominal pain and endocrine or exocrine dysfunction. It is a difficult illness to diagnose and manage making it a challenge for all involved…”

 

A list of recommended investigations is given. In the section on pain relief, it states:

 

“Pain relief
• The underlying cause of the pain is unclear
• Pain relief commonly requires opiates and there is a risk of opiate dependency. Simple analgesics should be used initially e.g. paracetamol and NSAIDs provided there are no contraindications.
• Opiates may also lead to gastroparesis
• ERCP may help reduce pain by dilating strictures of the pancreatic ducts
• Nerve blocks have also been used e.g. coeliac ganglionectomy or translumbar injection of local anaesthesia. Nerve blocks can also be given via EUS or CT - but this is invasive and only provides temporary relief.
It is important to make sure that there is not another cause for the pain e.g. pseudocyst, duct obstruction or dysmotility.

 

Some of these procedures may result in acute pancreatitis and other complications.

 

Patients who remain in pain despite the above measures may need to be referred for a surgical opinion (see below) and if there is likely to be a delay or they are unsuitable for surgery then they should be referred to local pain clinics.
There is also a section on pancreatic enzymes that reads:
“Pancreatic enzymes
Replacement of pancreatic enzymes can help malabsorption and also reduce pain e.g. Creon®. It is thought that the pancreatic enzymes provide negative feedback on pancreatic exocrine function. Randomized trials have shown this method to be effective in more than 50% of patients especially patients with small duct disease.

 

Furthermore, cholecystokinin (CCK) also stimulates the pancreas and is released from the small intestine by CCK releasing peptide. The CCK releasing peptide is broken down by proteases. Pancreatic enzymes that reach the small intestine can break down the CCK releasing peptide thereby halting pancreatic stimulation.

 

However, pancreatic enzymes are administered orally and are degraded by stomach fluid reducing the bioavailability. Acid suppressing medications can be administered at the same time with varying results.

 

Pancreatic enzymes are usually given as a trial for one month and if they are effective they are continued for six months and then they are withdrawn. 50% of patients will have long-term resolution of pain. However, if patients fail to respond then they should be considered for surgical procedures. One draw back of pancreatic enzymes is that it requires the taking of eight capsules at mealtimes and bedtime which may be difficult for some patients.” [1]

 

In addition, the SPC for Creon 10000 tablets lists the following undesirable effects:

 

“Diarrhoea, constipation, gastric discomfort, nausea and skin reactions have been reported occasionally in patients receiving enzyme replacement therapy.
Rarely cases of hyper-uricosuria and hyper-uricaemia have been reported with very high doses of pancreatin.
Stricture of the ileo-caecum and large bowel and colitis has been reported in children with cystic fibrosis taking high doses of pancreatic enzyme supplements. To date, Creon has not been implicated in the development of colonic damage. However, unusual abdominal symptoms or changes in abdominal symptoms should be reviewed to exclude the possibility of colonic damage - especially if the patient is taking in excess of 10,000 units of lipase/kg/day.” [2] 

 

It may be worth contacting the drug manufacturer for further information concerning Creon’s adverse effects:

 

Solvay HealthCare Limited
Tel: 02380 467 000
Email: medinfo.shl@solvay.com

 

References
1. PatientPlus. Chronic pancreatitis. September 2006. (http://www.patient.co.uk/showdoc/40002372/)
2. SPC for Creon 10000 capsules. 16th May 2007. (http://emc.medicines.org.uk/emc/industry/default.asp?page=displaydoc.asp&documentid=2068)

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