Gastrointestinal System

Pancreatic enzyme replacement is the mainstay of GI therapy. Most enzyme products are formulated as capsules containing enteric-coated microspheres or microtablets to avoid inactivation of enzymes by gastric acid; instead, they dissolve in the more alkaline environment of the duodenum. Capsules may be opened and the microbeads swallowed with food (for infants and young children), as long as they are not chewed or mixed with alkaline or hot foods, as enzymes may be denatured. A powder form is available for patients unable to swallow the capsules or microbeads, but bioavailability is poor. While products may contain similar enzyme ratios, they are not bio-equivalent and cannot be substituted. Generic enzyme products generally display poor

5 28

dissolution and should not be used. ' Table 16-4 lists commonly used enzyme replacement products. Note that enzyme formulations are frequently changing due to a newly mandated FDA approval process. Consult a specialized drug reference for updated product availability.

Pancreatic enzymes are initiated at 500 to 1,000 units/kg/meal of lipase component (because fats are the most difficult food components to digest) with half-doses given for snacks. Enzymes should be taken at the beginning or divided throughout the meal and must be given with any fat-containing snack. Infants are typically started at 1,500 to 2,500 units of lipase per 120 mL of formula or breast milk and may require division of capsule contents via visual estimation to obtain appropriate doses. Pancreatic enzymes cannot be placed in formula bottles due to inability to consistently pass through the nipple slit. Instead, enzyme microbeads are placed on a small dot of infant applesauce (or moistened infant rice cereal) and administered via infant spoon with subsequent nursing or bottle-feeding to facilitate swallowing. The oral mucosa must be examined afterward to ensure that all enzymes are swallowed, because remnant microbeads can cause oral erosions (ulcers).

Table 16-4 Common Pancreatic Enzyme Replacement Products

Lipase A my I as« Protease Trade Name4 (Units) {Units) (Units]

Enteric-Coated

Creoh 6,000

4,000

30,000

19,000

Creon 12,000

12,000

■10,000

38,000

Creon 24,000

24,000

120,000

76,000

Pandease

4,-SüO

2-\0OO

Páncneasé MT 4

4,000

ÍZOOO

12,000

PañcreaseM'l JO

10,000

30,000

30,000

Pane rea se MT 16

16,000

■18,000

48rooo

Pant reare MI 20

20r000

56,000

44,000

Pancrecarb .MS -4

>1,000

25,500

25,000

Pancrecarb .MS-8

8,000

40,000

45,000

Pancrecarb .MS-16

16,000

52rOOO

52,000

Ultraje

4500

20,000

25,000

Ultra se MT U

12r000

39,000

39,000

Ultra se MT 18

18,000

58,500

58,500

Ultrase MT 20

20r000

65,000

65,000

NonEnteric Coated

Viotai-e 3 tablet

3,000

30,000

30,000

Vlokase 16 tablet

16,000

60,000

60,000

Viokase powder

16,800

70,000

70,000

"The number after a trade name refers to the number of thousands of units of lipase contained per dosage form.

© Titration of pancreatic enzyme doses is based on control of steatorrhea, stool output, and abdominal symptoms. Infants should have no more than three to four stools per day, whereas older patients should have no more than two to three (children) or one to two (adolescents/adults) well-formed stools per day. Pancreatic enzymes are titrated at 2- to 3-week intervals in increments of 150 to 250 units of lipase/

kg/meal (or the next easily administered capsule or half-capsule). Doses up to 2,500 units/kg/meal may be needed, but higher doses should be used with caution due to the risk of fibrosing colonopathy.5,6,2 Patients who respond poorly to maximal doses of one product may benefit from changing to another product6 and/or addition of a histamine H2-receptor antagonist or proton pump inhibitor. Acid suppression may boost effective enzyme dose if duodenal pH is not alkaline enough to neutralize residual gastric acid and dissolve enteric coating as well as treat concomitant gastroeso-phageal reflux.5,6,28

Fat-soluble vitamin supplementation is usually required in pancreatic insufficiency. Specially-formulated products for CF patients (e.g., ADEKs, AquADEKs, SourceCF, and Vitamax) are usually sufficient to attain normal serum vitamin levels at a dose of one tablet daily for younger children and one tablet twice daily for teenagers and adults. Additional supplementation may be needed in uncontrolled malabsorption or for replacement of severe vitamin deficiency.5,28 Appetite stimulants such as cyproheptadine may be an option for promoting nutrition and weight gain, but efficacy has not been established.

The Prevention and Treatment of Headaches

The Prevention and Treatment of Headaches

Are Constant Headaches Making Your Life Stressful? Discover Proven Methods For Eliminating Even The Most Powerful Of Headaches, It’s Easier Than You Think… Stop Chronic Migraine Pain and Tension Headaches From Destroying Your Life… Proven steps anyone can take to overcome even the worst chronic head pain…

Get My Free Audio Book


Post a comment