Digestants (Pancreatin and Similar Drugs)

Pancreatin is a digestive enzyme produced by the exocrine glands of the pancreas and is necessary for the digestion of starch, fat and protein.

Indications¹

Pancreatin-insufficiency states:

• Cystic fibrosis
• Following pancreatomy or gastrectomy
• Chronic pancreatitis
• Pancreatic outflow obstruction eg. Due to tumour. Pancreatin can improve diarrhoea and quality of life in palliative care of patients with pancreatic cancer.²

Cautions

The CSM advises that higher strength pancreatin preparations (Nutrizym 22® and Pancreatin HL®) have been associated with the development of large bowel strictures in children with CF aged between 2 and 13.³ Risk factors are: male sex, more severe CF and concomitant laxative use.

• These preparations should not be used in children aged 15 years or less.
• The total dose of pancreatic enzyme supplementation in CF should not exceed 10 000 units of lipase per kg of body weight/day.
• If new or altered abdominal symptoms develop whilst taking pancreatin preparations, the patient should be reviewed to exclude colonic damage.

Side-effects¹

• Irritation of the perioral skin and buccal mucosa - do not retain in the mouth
• Perianal irritation with high doses
• GI side-effects are common - nausea, vomiting, abdominal discomfort
• Hyperuricaemia and hyperuricosuria are associated with high doses
• Hypersensitivity reactions are rarer and can occur in those handling the powder as well as those ingesting it.

Using pancreatin supplements^1,4

• Take with food (or immediately before or after) as gastric acid inactivates the enzyme.
• Reducing gastric acid secretions by taking with a H2-Receptor Antagonist or PPI may improve fat digestion and absorption. However a Cochrane Review found only limited evidence of nutritional benefit but some of improvement in GI symptoms with the use of drugs to reduce gastric acidity in people with cystic fibrosis.⁵
• Enteric-coating delivers a higher enzyme concentration in the duodenum (do not chew these capsules).
• Avoid contact with excess heat . Do not mix with hot fluid or food as this will inactivate the enzyme.
• Similarly avoid keeping food/liquid mixtures with pancreatin for more than one hour as again the enzyme will become denatured.
• Dose should be titrated to size, number and consistency of stools.
• Extra allowance should be made if snacks are taken between meals.