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Pancreatic Enzyme Replacement Therapy
Pancreatic cancer is an aggressive malignancy and the seventh leading cause of global cancer deaths in industrialised countries. More than 80% of patients suffer from significant weight loss at diagnosis and over time tend to develop severe cachexia. A major cause of weight loss is malnutrition. Patients may experience pancreatic exocrine insufficiency (PEI) before diagnosis, during nonsurgical treatment, and/or following surgery. PEI is difficult to diagnose because testing is cumbersome. Consequently, PEI is often detected clinically, especially in non-specialised centres, and treated empirically.
2. Maldigestion in Resected Pancreatic Cancer
3. Pancreatic Enzyme Replacement Therapy: Tips and Tricks
3.1. Dosage Challenges
3.2. Dietary and Drug Recommendation
3.3. Goal of the Treatment
3.4. Warnings Regarding PERT
|Nutritional Support Principles in Pancreatic Cancer|
|Early nutritional support, starting with individualised dietary counselling and possibly implementing artificial nutrition, is mandatory in all pancreatic cancer (PC) patients at nutritional risk, as it is able to improve clinical outcomes and reduce treatment complications.|
|Considering the high prevalence of nutritional derangements in PC, we recommend to refer every patient with PC to a clinical nutrition specialists for implementing prophylactic nutritional monitoring and/or counselling.|
|Dietary advice should be tailored to the individual patient and “hypocaloric alternative anticancer diets” and “natural nutrients” not supported by clinical evidence should be avoided.|
|Real life diagnostic approach to maldigestion|
|Although a validated “gold standard” method to assess pancreatic enzyme insufficiency (PEI) is lacking, faecal elastase is generally used in clinical practice, as it is promptly available and least invasive.|
|Treatment of PEI using pancreatic enzyme replacement therapy (PERT) should start as soon as PEI is diagnosed (even if the patient is asymptomatic) or when a high clinical suspicion of PEI is present.|
|In patients with the tumour located at the head of the pancreas, the prevalence of PEI is so high that all patients should be treated with PERT, even without testing.|
|Maldigestion in unresectable and metastatic pancreatic cancer|
|Despite that large randomised clinical trials are missing, the data in literature indicate that PERT can enhance nutritional status, allowing the patient to undergo chemotherapy (CT), increase quality of life (QoL) and overall survival (OS).|
|Maldigestion in borderline/locally advanced setting|
|There is a big gap on information regarding the prevalence of PEI in the borderline/locally advanced setting, and the potential of PERT in this setting.|
|Malnutrition is important in the neoadjuvant setting: on the one hand, neoadjuvant chemotherapy (NACT) may impair the functional reserve and lead to nutritional status changes. On the other hand, weight loss and loss of muscle mass are limiting factors for CT choice, delivery, and tolerance and contribute to reducing a person’s ability to undergo surgery.|
|Locally advanced (LA)/borderline resectable (BR) pancreatic cancer patients should always be assessed for PEI and nutritional status before starting NACT, closely monitored during treatment, and supported with PERT and nutritional counselling as appropriate.|
|Maldigestion in resected pancreatic cancer|
|Patients submitted to pancreaticoduodenectomy (PD) should be considered at high risk for developing PEI, especially in the presence of PC. We recommend to start PERT routinely in these patients, especially in those who will undergo adjuvant CT.|
|Most PC patients suffering from PEI are undertreated which can result in malnutrition and frailty, reducing patient’s ability to undergo major surgery and CT. An adequate treatment of PEI is therefore essential for patients affected by resectable PC, both before surgery, especially if they undergo NACT, and after surgery, to guarantee a proper postoperative recovery and the capacity to tolerate adjuvant CT.|
|Pancreatic enzyme replacement therapy: tips and tricks|
|The initial recommended dose of pancreatic extract which should be given is 40,000–50,000 U.Ph.Eur of lipase per meal and 25,000 U.Ph.Eur per snack, and this dose should be increased until the steatorrhea is sufficiently reduced. This dosage should be maintained over time.
Dose optimisation of PERT is necessary for an effective management of PEI, in addition to regular evaluation of nutritional status, appropriate patient education and reassessment whenever symptoms return.
|Food intake should be distributed between three main meals per day and two or three snacks. The pancreatic extracts should be ingested during the meals. The caloric intake should not be restricted.|
|A diet rich in fibre is contraindicated because the fibrous material will interfere with enzyme activity|
|Crushing, chewing or holding the pancreatic extract capsules in the mouth may cause local irritation.|
The entry is from 10.3390/cancers12020275
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