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Starting a Pancreatic Enzyme Replacement Therapy (PERT) and Patient Counseling
04/08/2024
Transcript:
Welcome, and thank you for watching this video series on the patient experience and clinical insights into PERT, pancreatic enzyme replacement therapy. I'm Dr Allison Yang. I'm a board-certified gastroenterologist specializing in pancreatic diseases. I'm excited to review this important topic. So, let's get started.
This is the second video of a 3-part series. In this video, we will discuss initiating PERT, as well as patient counseling. Let's start with a brief overview. Exocrine pancreatic insufficiency, or EPI, is the reduced production, secretion, or activity of pancreatic enzymes and/or bicarbonate. The normal pancreas secretes an average of 720,000 units of lipase per meal. Fat malabsorption and subsequent steatorrhea typically occur when lipase output is less than 10% of normal output.
It's estimated that giving 10% of normal pancreatic lipase output is enough to prevent some steatorrhea. PERT helps EPI patients replace some of the pancreatic enzymes. EPI is often underdiagnosed and undertreated, so finding the appropriate PERT dose is of paramount importance.
Starting PERT may be challenging for both patients and clinicians for a few reasons. There are no US-based guidelines or consensus documents solely for the management of EPI, leaving physicians to rely on the 2008 Cystic Fibrosis Foundation Consensus Conference guidelines for PERT dosing. Guidelines state the following for adults. This is considered weight-based dosing.
Additional dosing options include fat content of the patient diet and underlying conditions that were studied. Clinicians can use either an actual body weight or fat ingestion-based dosing scheme. Because the specific fat content of meals can be difficult to determine, weight-based dosing may be more practical.
So, in general, start PERT at the lowest recommended dosage and individualize the dosage based on clinical symptoms, the degree of steatorrhea present, and the fat content of the diet. The American College of Gastroenterology guidelines for chronic pancreatitis recommend that an adequate dose of 40,000 to 50,000 USP units of lipase should be administered with each meal.
For snacks, use approximately half the prescribed dose for a meal. If signs and symptoms of malabsorption persist, the dosage may be increased.
In my clinical practice, I generally counsel patients to take half of the capsules at the first bite of the meal and the remaining half midway through the meal if the meal lasts more than 20 minutes. This is to mimic the postprandial enzyme secretion of the normal pancreas physiology.
Now, let's further discuss the importance of patient counseling. Patients may be overwhelmed when receiving the diagnosis of a potentially lifelong condition. Therefore, it's helpful to provide comprehensive patient education.
Clinicians should discuss the various aspects of treatment with PERT, including dosing, timing, and treatment experience. One of the biggest challenges noted by patients is remembering to take PERT with every meal and every snack.
When taking PERT with meals, enteric-coated enzyme capsules can be opened and the contents mixed with an acidic food such as applesauce, but they should not be crushed or allowed to remain in the food as this can cause inactivation.
I always remind my patients that lifestyle modifications are also important. This includes stopping smoking and alcohol consumption and meeting with dietitians or nutritionists for further dietary advice. Symptom and weight tracking can be helpful, and there are many tracking tools available to patients.
Since PERT dosing and the patient experience can be complex, patient counseling on these points should be an integral part of starting treatment with PERT.
In summary, there's a lack of US-based guidelines for the management of EPI, and there are different approaches to dosing pancreatic enzymes, which can make it all confusing. Remember to refer to the respective product package inserts for specific dosing information, and include this information as part of patient counseling for patients starting treatment. Clear guidance and good patient–physician communication are important components of EPI management.
Thank you for listening. I encourage you to test your knowledge with the post-test question and view the next video in the series.
ABBV-US-01479-MC
Approved 04/2024
AbbVie Medical Affairs
Allison Yang, MD, MPH
Dr Allison Yang is the medical director of the Pancreas Program at Weill Cornell Medicine. She is an Assistant Professor of Medicine at Weill Cornell Medical College and Attending Physician at New York Presbyterian Hospital/Weill Cornell Medical Center. She is a clinical gastroenterologist with a focus on the multi-disciplinary care of patients with pancreatic disease.
Dr Yang received her BA from Columbia University in New York, her MD from the University of Illinois, and her MPH from the Harvard School of Public Health. She completed her internal medicine residency training at the Mayo Clinic, and her gastroenterology fellowship at Brigham and Women’s Hospital/Harvard Medical School.
Dr Yang’s primary clinical and research interests are in the effective diagnosis and treatment of pancreatic disease including acute and chronic pancreatitis, recognition and treatment of cystic neoplasms of the pancreas, and management of high-risk pancreas patients.
