Ph. U of lipase
per meal and 20 000–25 000 Eur. Ph. U of lipase together with snacks should be given. In cases of insufficient response, inhibition of gastric acid secretion should be attempted. Finally, bacterial overgrowth should be detected and treated in non-responders (Fig. 2). As mentioned above, a low intraduodenal pH may inactivate endogenous and uncoated exogenous lipase, prevent the release of active lipase from enteric-coated granules within the proximal intestine, and lead to bile salt precipitation. Inhibition of gastric acid secretion, by increasing the intragastric pH and thus decreasing the duodenal acid load, should improve the efficacy of the enzyme substitution CX-5461 in vitro therapy. Combining enteric-coated pancreatin microspheres with either a H2-receptor antagonist or a proton pump inhibitor was reported to be beneficial in patients with cystic fibrosis.24,25 More recently, addition of a proton pump inhibitor has been shown to significantly improve and even normalize fat digestion in patients with pancreatic exocrine insufficiency and incomplete response to the enzyme substitution therapy in form www.selleckchem.com/products/LDE225(NVP-LDE225).html of enteric-coated minimicrospheres.18 This combined therapy, however, should not be used in patients with an adequate response to the enzyme substitution monotherapy.18 Independently of the therapy prescribed,
evaluation of the therapeutic efficacy of pancreatic enzymes is generally based on clinical parameters like weight gain or absence of weight loss, and improvement of steatorrhea-related symptoms. This clinical evaluation has been recently shown to be inappropriate, and only normalization of fat digestion, demonstrated by means of objective methods like normalization of CFA, 13C-MTG breath test, or specific nutritional parameters,
ensures a normal nutritional status in patients with pancreatic exocrine insufficiency.6,8 Pancreatic exocrine insufficiency develops in most patients after partial or total gastrectomy and duodenopancreatectomy.26,27 Multiple factors have been implicated, including decreased postprandial stimulation of pancreatic secretion secondary to the disruption of neural reflexes and reduced cholecystokinin (CCK) release, primarily decreased 上海皓元 pancreatic secretion, arrival of big, hard-to-digest nutrient particles to the jejunal lumen due to pylorus resection, and postprandial asynchrony between gastric emptying of nutrients and biliopancreatic secretion.26–28 Despite the relevance of pancreatic exocrine insufficiency in the nutritional status of operated patients, the number of studies evaluating the usefulness of pancreatic enzyme substitution therapy in this setting is limited, and data regarding the best preparation to be used are scarce.28 Enteric-coated enzyme microspheres have been shown to be associated with a higher body weight gain compared with uncoated preparations in patients after duodenopancreatectomy.