From Bcrardi RR Montgomery PA Pancreatitis In DiPiroJT Talbert RL Yee GC et a I eds Pharmacotherapy A Pal ho physio loyic Approach 7th ed New York McGraw Hill 2003670 with permission

Nonenteric-coated pancreatic enzyme supplements can be used for initial therapy. The relative dose of amylase, lipase, and protease maybe increased until control of pain and fatty diarrhea are achieved or the patient experiences intolerable side effects. If pain and diarrhea control are achieved, the patient can be transitioned to an enteric-coated supplement to maximize compliance. A reasonable example starting regimen is Viokase-8, six tablets with each meal and at bedtime, given with famotidine 20 mg at bedtime.

Patient Encounter 2

The same patient described in the first encounter is now 34 years old (she delivered a healthy baby boy without complications). She presents to the clinic with RUQ pain radiating to her back. She is also jaundiced and nauseated.

PMH: Gravida 2 para 2, cholelithiasis

SH: Consumes one to two alcoholic beverages per evening; no tobacco

Meds: Multivitamin one tablet daily; pantoprazole 40 mg orally once daily; maalox 15 mL orally four times daily as needed for heartburn/stomach upset; acetaminophen 325 mg orally every 6 hours as needed for pain/headache

ROS: Positive for sharp RUQ abdominal pain radiating to the back, nausea, and recent unintentional weight loss; negative for chest pain or shortness of breath, fatty diarrhea present for months

VS: BP 130/86 mm Hg, p 80 bpm, RR 16 per minute, T 37.0°C (98.6°F), wt 80 kg (176 lb), ht 5'5" (165 cm).

CV: Regular rate and rhythm, no murmurs noted

Abd: Distended, (+) rebound tenderness, (+) bowel sounds, marked hepatospleno-megaly

Labs: Amylase 100 units/L (1.67 ^Kat/L), lipase 100 units/L (1.67 ^Kat/L)

CT Scan: Diffuse pancreatic scarring and calcifications

Formulate a care plan for this patient.

Why are the serum amylase and lipase normal?

What lifestyle modifications can this patient make to minimize impact from her disease state?

Is this patient taking any medication(s) that could exacerbate pancreatitis? If so, what alternatives can you offer?

What medications may help alleviate the fatty diarrhea the patient is experiencing? How wouldyou monitor the effectiveness of your recommendations?

Most pancreatic enzyme supplements are enteric coated to release enzymes in the alkaline environment of the intestine; this minimizes enzyme destruction in the stomach. Enteric-coated pancreatic enzyme supplements require fewer daily dosage units, but delivery of the drug to the site of action and effectiveness may be delayed by gast-

ric emptying time.

Pancreatic enzyme supplements should be taken immediately prior to meals to aid in the digestion and absorption of food. Alternately, patients can supplement their diet with medium-chain triglycerides (MCTs) or ingest foods rich in MCTs since they do not require pancreatic enzymes for absorption. An appropriate regimen incorporates the successful doses of each enzyme (amylase, lipase, and protease) from the starting Nonenteric-coated regimen. As with the previous example, a patient stabilized on Viokase-8, six tablets with each meal, can be transitioned to Pancrease MT-16 three tablets with meals. The famotidine can then be discontinued.

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