Abstract
We describe the rational use of enteric coated and unprotected replacement pancreatic enzymes for treatment of malabsorption due to pancreatic insufficiency and for pancreatic pain. Enteric coated formulations mix poorly with food allowing separation of enzymes and nutrients when emptying from the stomach. The site of dissolution of the enteric coating in the intestine is also unpredictable and enzymes may not be released until the distal intestine. Together, these barriers result in the lack of dose-response such that the strategy of increasing the dosage following a suboptimal effect is often ineffective. The ability to maintain the intragastric pH ≥4 with the combination of proton pump inhibitors and antacids suggests that it should be possible to reliably obtain a good response with uncoated enzymes. We also discuss the recognition, treatment and prevention of nutritional deficiencies associated with pancreatic insufficiency and recommend a test and treat strategy to identify and resolve nutritional deficits. Finally, we focus on mechanisms causing pain that may be amenable to therapy with pancreatic enzymes. Pain due to malabsorbed digestive contents can be prevented by successful therapy of malabsorption. Feedback inhibition of endogenous pancreatic secretion can prevent pain associated with pancreatic secretion but requires use of non-enteric coated formulations.
Author Contributions: Each of the authors have been involved equally in study design, data acquisition, analysis, interpretation and drafting the article. All have read and approved the final manuscript. Each meets the criteria for authorship established by the International Committee of Medical Journal Editors and verify the validity of the results reported.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Abbreviations
- CCK:
-
Cholecystokinin
- CFA:
-
Coefficient of fat absorption
- FDA:
-
Food and Drug Administration
- INR:
-
International normalized ratio
- RBP:
-
Retinol binding protein
References
Adler G, Mullenhoff A, Bozkurt T, Goke B, Koop I, Arnold R (1988a) Comparison of the effect of single and repeated administrations of a protease inhibitor (Camostate) on pancreatic secretion in man. Scand J Gastroenterol 23(2):158–162
Adler G, Mullenhoff A, Koop I, Bozkurt T, Goke B, Beglinger C, Arnold R (1988b) Stimulation of pancreatic secretion in man by a protease inhibitor (camostate). Eur J Clin Investig 18(1):98–104
Afghani E, Sinha A, Singh VK (2014) An overview of the diagnosis and management of nutrition in chronic pancreatitis. Nutr Clin Pract 29(3):295–311
Aloulou A, Puccinelli D, Sarles J, Laugier R, Leblond Y, Carriere F (2008) In vitro comparative study of three pancreatic enzyme preparations: dissolution profiles, active enzyme release and acid stability. Aliment Pharmacol Ther 27(3):283–292
Bakowski MT, Prescott P (1997) Patterns of use of pancreatic enzyme supplements in fibrosing colonopathy: implications for pathogenesis. Pharmacoepidemiol Drug Saf 6(5):347–358
Beazell JM, Schmidt CR, Ivy AC (1941) The diagnosis and treatment of achylia pancreatica. JAMA 116(25):2735–2739
Bell NJ, Burget D, Howden CW, Wilkinson J, Hunt RH (1992) Appropriate acid suppression for the management of gastro-oesophageal reflux disease. Digestion 51(Suppl 1):59–67
Benini L, Caliari S, Guidi GC, Vaona B, Talamini G, Vantini I, Scuro LA (1989) Near infrared spectrometry for faecal fat measurement: comparison with conventional gravimetric and titrimetric methods. Gut 30(10):1344–1347
Bernstein CN, Leslie WD, Leboff MS (2003) AGA technical review on osteoporosis in gastrointestinal diseases. Gastroenterology 124(3):795–841
Borowitz D, Gelfond D (2013) Intestinal complications of cystic fibrosis. Curr Opin Pulm Med 19(6):676-680. Available from: PM:24060981
Borowitz D, Baker RD, Stallings V (2002) Consensus report on nutrition for pediatric patients with cystic fibrosis. J Pediatr Gastroenterol Nutr 35(3):246–259
Bruno MJ, Rauws EA, Hoek FJ, Tytgat GN (1994) Comparative effects of adjuvant cimetidine and omeprazole during pancreatic enzyme replacement therapy. Dig Dis Sci 39(5):988–992
Chase RF (1905) The therapeutic value of some digestive preparations, and the indications for use of pepsin, in diseases of the stomach. Boston Med Surg J 152:572–574
Chernick SS, Lepkovsky S, Chaikoff IL (1948) A dietary factor regulating the enzyme content of the pancreas; changes induced in size and proteolytic activity of the chick pancreas by the ingestion of raw soy-bean meal. Am J Phys 155(1):33–41
Corring T (1973) Mechanism of the exocrine pancreatic secretion in the pig feed-back regulation. Ann Biol Amin Biochim Biophys 13:755–756
Czako L, Takacs T, Hegyi P, Pronai L, Tulassay Z, Lakner L, Dobronte Z, Boda K, Lonovics J (2003) Quality of life assessment after pancreatic enzyme replacement therapy in chronic pancreatitis. Can J Gastroenterol 17(10):597–603
Delchier JC, Vidon N, Saint-Marc Girardin MF, Soule JC, Moulin C, Huchet B, Zylberberg P (1991) Fate of orally ingested enzymes in pancreatic insufficiency: comparison of two pancreatic enzyme preparations. Aliment Pharmacol Ther 5(4):365–378
Diamond JS, Siegel SA, Kantor JL, Jour DD (1940) The secretin test in the diagnosis of pancreatic diseases with a report of one hundred thirty tests. Am J Dig Dis 7(10):435–442
DiMagno EP, Go VL, Summerskill WH (1973) Relations between pancreatic enzyme outputs and malabsorption in severe pancreatic insufficiency. N Engl J Med 288(16):813–815
DiMagno EP, Malagelada JR, Go VL, Moertel CG (1977) Fate of orally ingested enzymes in pancreatic insufficiency comparison of two dosage schedules. N Engl J Med 296(23):1318–1322
Dominguez-Munoz JE (2007) Pancreatic enzyme therapy for pancreatic exocrine insufficiency. Curr Gastroenterol Rep 9(2):116–122
Dominguez-Munoz JE (2011) Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency: when is it indicated, what is the goal and how to do it? Adv Med Sci 56(1):1–5
Dominguez-Munoz JE, Iglesias-Garcia J (2010) Oral pancreatic enzyme substitution therapy in chronic pancreatitis: is clinical response an appropriate marker for evaluation of therapeutic efficacy? JOP 11(2):158–162
Dominguez-Munoz JE, Iglesias-Garcia J, Iglesias-Rey M, Figueiras A, Vilarino-Insua M (2005) Effect of the administration schedule on the therapeutic efficacy of oral pancreatic enzyme supplements in patients with exocrine pancreatic insufficiency: a randomized, three-way crossover study. Aliment Pharmacol Ther 21(8):993–1000
Dominguez-Munoz JE, Iglesias-Garcia J, Vilarino-Insua M, Iglesias-Rey M (2007) 13C-mixed triglyceride breath test to assess oral enzyme substitution therapy in patients with chronic pancreatitis. Clin Gastroenterol Hepatol 5(4):484–488
Dreiling DA, Hollander F (1948) Studies in pancreatic function; preliminary series of clinical studies with the secretin test. Gastroenterology 11(5):714–729
Duggan SN, Smyth ND, O’Sullivan M, Feehan S, Ridgway PF, Conlon KC (2014) The prevalence of malnutrition and fat-soluble vitamin deficiencies in chronic pancreatitis. Nutr Clin Pract 29(3):348–354
Durie PR, Bell L, Linton W, Corey ML, Forstner GG (1980) Effect of cimetidine and sodium bicarbonate on pancreatic replacement therapy in cystic fibrosis. Gut 21(9):778–786
Ebbehoj N, Borly L, Bulow J, Rasmussen SG, Madsen P (1990) Evaluation of pancreatic tissue fluid pressure and pain in chronic pancreatitis a longitudinal study. Scand J Gastroenterol 25(5):462–466
Engesser H (1879) Beitrage zur therapeutischen Verwendung der Bauchspeicheldruse von Schlachtthieren und deren praparate. Dtsch Arch Klin Med 24:539–582
Fordtran JS, Morawski SG, Richardson CT (1973) In vivo and in vitro evaluation of liquid antacids. N Engl J Med 288(18):923–928
Forsmark CE (2016) Chronic pancreatitis. In: Feldman M, Friedman LS, Brandt LJ (eds) Sleisenger and Fordtran’s gastrointestinal and liver disease, 10th edn. Elsevier Saunders, Philadelphia, p 1020
Franzen D, Went P, Buhlmann U (2008) Fibrosing colonopathy in absence of pancreatic enzyme supplementation in one adult patient with cystic fibrosis. Indian J Gastroenterol 27(3):133–134
Gaia E, Sambatoro A, De Giuli P, Angeli A (2001) Adult fibrosing colonopathy associated with mesalazine treatment. Am J Gastroenterol 96(8):2508–2509
Gow R, Bradbear R, Francis P, Shepherd R (1981) Comparative study of varying regimens to improve steatorrhoea and creatorrhoea in cystic fibrosis: effectiveness of an enteric-coated preparation with and without antacids and cimetidine. Lancet 2(8255):1071–1074
Graham DY (1977) Enzyme replacement therapy of exocrine pancreatic insufficiency in man relations between in vitro enzyme activities and in vivo potency in commercial pancreatic extracts. N Engl J Med 296(23):1314–1317
Graham DY (1979) An enteric-coated pancreatic enzyme preparation that works. Dig Dis Sci 24(12):906–909
Graham DY (1982) Pancreatic enzyme replacement: the effect of antacids or cimetidine. Dig Dis Sci 27(6):485–490
Graham DY, Dore MP (2018) Update on the use of vonoprazan: a competitive acid blocker. Gastroenterology 154(154):462–466
Graham DY, Sackman JW (1982) Mechanism of increase in steatorrhea with calcium and magnesium in exocrine pancreatic insufficiency: an animal model. Gastroenterology 83(3):638–644
Graham DY, Sackman JW (1983) Solubility of calcium soaps of long-chain fatty acids in simulated intestinal environment. Dig Dis Sci 28(8):733–736
Graham DY, Tansel A (2018) Interchangeable use of proton pump inhibitors based on relative potency. Clin Gastroenterol Hepatol 16(6):800–808
Green GM, Lyman RL (1972) Feedback regulation of pancreatic enzyme secretion as a mechanism for trypsin inhibitor-induced hypersecretion in rats. Proc Soc Exp Biol Med 140(1):6–12
Gubergrits N, Malecka-Panas E, Lehman GA, Vasileva G, Shen Y, Sander-Struckmeier S, Caras S, Whitcomb DC (2011) A 6-month, open-label clinical trial of pancrelipase delayed-release capsules (Creon) in patients with exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatic surgery. Aliment Pharmacol Ther 33(10):1152–1161
Harris R, Norman AP, Payne WW (1955) The effect of pancreatin therapy on fat absorption and nitrogen retention in children with fibrocystic disease of the pancreas. Arch Dis Child 30(153):424–427
Heijerman HG, Lamers CB, Bakker W (1991) Omeprazole enhances the efficacy of pancreatin (pancrease) in cystic fibrosis. Ann Intern Med 114(3):200–201
Heubi JE, Schaeffer D, Ahrens RC, Sollo N, Strausbaugh S, Graff G, Jain R, Witte S, Forssmann K (2016) Safety and efficacy of a novel microbial lipase in patients with exocrine pancreatic insufficiency due to cystic fibrosis: a randomized controlled clinical trial. J Pediatr 176:156–161e1
Hobbs PM, Johnson WG, Graham DY (2016) Management of pain in chronic pancreatitis with emphasis on exogenous pancreatic enzymes. World J Gastrointest Pharmacol Ther 7(3):370–386
Hunt JN (1983) Mechanisms and disorders of gastric emptying. Annu Rev Med 34:219–229
Hunt JN, Knox MT (1968) Control of gastric emptying. Am J Dig Dis 13(4):372–375
Hunt RH, Cederberg C, Dent J, Halter F, Howden C, Marks IN, Rune S, Walt RP (1995) Optimizing acid suppression for treatment of acid-related diseases. Dig Dis Sci 40(2 Suppl):24S–49S
Ianiro G, Pecere S, Giorgio V, Gasbarrini A, Cammarota G (2016) Digestive enzyme supplementation in gastrointestinal diseases. Curr Drug Metab 17(2):187–193
Ihse I, Lilja P, Lundquist I (1979) Trypsin as a regulator of pancreatic secretion in the rat. Scand J Gastroenterol 14(7):873–880
Jones DB, Howden CW, Burget DW, Kerr GD, Hunt RH (1987) Acid suppression in duodenal ulcer: a meta-analysis to define optimal dosing with antisecretory drugs. Gut 28(9):1120–1127
Jordan PH Jr, Grossman MI (1959) Effect of dosage schedule on the efficacy of substitution therapy in pancreatic insufficiency. Gastroenterology 36(4):447–451
Julapall VR, Graham DY (2005) Appropriate use of intravenous proton pump inhibitors in the management of bleeding peptic ulcer. Dig Dis Sci 50(7):1185–1193
Kalser MH, Leite CA, Warren WD (1968) Fat assimilation after massive distal pancreatectomy. N Engl J Med 279(11):570–576
Kattwinkel J, Agus SG, Taussig LM, di Sant’Agnese PA, Laster L (1972) The use of L-arginine and sodium bicarbonate in the treatment of malabsorption due to cystic fibrosis. Pediatrics 50(1):133–137
Keller J, Layer P (2005) Human pancreatic exocrine response to nutrients in health and disease. Gut 54(Suppl 6):vi1–v28
Keller J, Runzi M, Goebell H, Layer P (1997) Duodenal and ileal nutrient deliveries regulate human intestinal motor and pancreatic responses to a meal. Am J Phys 272(3 Pt 1):G632–G637
Ketwaroo G, Brown A, Young B, Kheraj R, Sawhney M, Mortele KJ, Najarian R, Tewani S, Dasilva D, Freedman S, Sheth S (2013) Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis. Am J Gastroenterol 108(8):1360–1366
Kirchheiner J, Glatt S, Fuhr U, Klotz U, Meineke I, Seufferlein T, Brockmoller J (2009) Relative potency of proton-pump inhibitors-comparison of effects on intragastric pH. Eur J Clin Pharmacol 65(1):19–31
Kuhn RJ, Eyting S, Henniges F, Potthoff A (2007) In vitro comparison of physical parameters, enzyme activity, acid resistance, and pH dissolution characteristics of enteric-coated pancreatic enzyme preparations: implications for clinical variability and pharmacy substitution. J Pediatr Pharmacol Ther 12(2):115–128
da la Iglesia-García D, Huang W, Szatmary P, Baston-Rey I, Gonzalez-Lopez J, Prada-Ramallal G, Mukherjee R, Nunes QM, Dominguez-Munoz JE, Sutton R (2017) Efficacy of pancreatic enzyme replacement therapy in chronic pancreatitis: systematic review and meta-analysis. Gut 66(8):1354–1355
da la Iglesia-García D, Vallejo-Senra N, Iglesias-Garcia J, Lopez-Lopez A, Nieto L, Dominguez-Munoz JE (2018) Increased risk of mortality associated with pancreatic exocrine insufficiency in patients with chronic pancreatitis. J Clin Gastroenterol 52(8):e63–e72
Layer P, Keller J (1999) Pancreatic enzymes: secretion and luminal nutrient digestion in health and disease. J Clin Gastroenterol 28(1):3–10
Layer P, Go VL, DiMagno EP (1986) Fate of pancreatic enzymes during small intestinal aboral transit in humans. Am J Phys 251(4 Pt 1):G475–G480
Liener IE, Goodale RL, Deshmukh A, Satterberg TL, Ward G, DiPietro CM, Bankey PE, Borner JW (1988) Effect of a trypsin inhibitor from soybeans (Bowman-Birk) on the secretory activity of the human pancreas. Gastroenterology 94(2):419–427
Lindkvist B, Dominguez-Munoz JE, Luaces-Regueira M, Castineiras-Alvarino M, Nieto-Garcia L, Iglesias-Garcia J (2012) Serum nutritional markers for prediction of pancreatic exocrine insufficiency in chronic pancreatitis. Pancreatology 12(4):305–310
Lindkvist B, Phillips ME, Dominguez-Munoz JE (2015) Clinical, anthropometric and laboratory nutritional markers of pancreatic exocrine insufficiency: prevalence and diagnostic use. Pancreatology 15(6):589–559
Littman A, Hanscom DH (1969) Current concepts: pancreatic extracts. N Engl J Med 28(4):201–204
Louie DS, May D, Miller P, Owyang C (1986) Cholecystokinin mediates feedback regulation of pancreatic enzyme secretion in rats. Am J Physiol 250(2 Pt 1):G252–G259
Lowe ME, Whitcomb DC (2015) Next generation of pancreatic enzyme replacement therapy: recombinant microbial enzymes and finding the perfect lipase. Gastroenterology 149(7):1678–1681
Marotta F, O’Keefe SJ, Marks IN, Girdwood A, Young G (1989) Pancreatic enzyme replacement therapy: importance of gastric acid secretion, H2-antagonists, and enteric coating. Dig Dis Sci 34(3):456–461
Meyer JH (1980) Gastric emptying of ordinary food: effect of antrum on particle size. Am J Phys 239(3):G133–G135
Meyer JH, Lake R (1997) Mismatch of duodenal deliveries of dietary fat and pancreatin from enterically coated microspheres. Pancreas 15(3):226–235
Meyer JH, Elashoff J, Porter-Fink V, Dressman J, Amidon GL (1988) Human postprandial gastric emptying of 1-3-millimeter spheres. Gastroenterology 94(6):1315–1325
Mossner J (1991) Treatment of pain in chronic pancreatitis with pancreatic enzymes another point of view. In: Lankisch PG (ed) Pancreatic enzymes in health and disease. Springer-Verlag, Berlin, pp 103–112
Mullady DK, Yadav D, Amann ST, O’Connell MR, Barmada MM, Elta GH, Scheiman JM, Wamsteker EJ, Chey WD, Korneffel ML, Weinman BM, Slivka A, Sherman S, Hawes RH, Brand RE, Burton FR, Lewis MD, Gardner TB, Gelrud A, DiSario J, Baillie J, Banks PA, Whitcomb DC, Anderson MA (2011) Type of pain, pain-associated complications, quality of life, disability and resource utilisation in chronic pancreatitis: a prospective cohort study. Gut 60(1):77–84
Owyang C, Louie DS, Tatum D (1986a) Feedback regulation of pancreatic enzyme secretion suppression of cholecystokinin release by trypsin. J Clin Invest 77(6):2042–2047
Owyang C, May D, Louie DS (1986b) Trypsin suppression of pancreatic enzyme secretion differential effect on cholecystokinin release and the enteropancreatic reflex. Gastroenterology 91(3):637–643
Pelley JR, Gordon SR, Gardner TB (2012) Abnormal duodenal [HCO3-] following secretin stimulation develops sooner than endocrine insufficiency in minimal change chronic pancreatitis. Pancreas 41(3):481–484
Poulsen JL, Olesen SS, Malver LP, Frokjaer JB, Drewes AM (2013) Pain and chronic pancreatitis: a complex interplay of multiple mechanisms. World J Gastroenterol 19(42):7282–7291
Prescott P, Bakowski MT (1999) Pathogenesis of fibrosing colonopathy: the role of methacrylic acid copolymer. Pharmacoepidemiol Drug Saf 8(6):377–384
Prieto G, Perez-Moneo B, Molina M, Ramos E, Sarria J, Larrauri J, Tovar JA (2009) Fibrosing colonopathy associated with treatment with enteric-coated mesalazine pills. Inflamm Bowel Dis 15(10):1452–1453
Ramesh H, Reddy N, Bhatia S, Rajkumar JS, Bapaye A, Kini D, Kalla M, Thorat V (2013) A 51-week, open-label clinical trial in India to assess the efficacy and safety of pancreatin 40000 enteric-coated minimicrospheres in patients with pancreatic exocrine insufficiency due to chronic pancreatitis. Pancreatology 13(2):133–139
Rausch U, Weidenbach H, Adler G, Kern HF (1987) Stimulation of pancreatic secretory process in the rat by low-molecular weight proteinase inhibitor II regulation of total protein and individual enzyme biosynthesis. Cell Tissue Res 249(1):63–67
Regan PT, Malagelada JR, DiMagno EP, Go VL (1979) Reduced intraluminal bile acid concentrations and fat maldigestion in pancreatic insufficiency: correction by treatment. Gastroenterol 77(2):285–289
Rogers CL (2013) Nutritional management of the adult with cystic fibrosis – part I. Pract Gastroenterol 113(1):10–24
Sander-Struckmeier S, Beckmann K, Janssen-van SG, Pollack P (2013) Retrospective analysis to investigate the effect of concomitant use of gastric acid-suppressing drugs on the efficacy and safety of pancrelipase/pancreatin (CREON(R)) in patients with pancreatic exocrine insufficiency. Pancreas 42(6):983–989
Scharpé S, Uyttenbroeck W, Samyn N (1997) In: Lauwers A, Scharpé S (eds) Pancreatic enzyme replacement. Taylor Francis, London, pp 187–221
Shiratori K, Chen YF, Chey WY, Lee KY, Chang TM (1986) Mechanism of increased exocrine pancreatic secretion in pancreatic juice-diverted rats. Gastroenterology 91(5):1171–1178
Sikkens EC, Cahen DL, Eijck C, Kuipers EJ, Bruno MJ (2012) Patients with exocrine insufficiency due to chronic pancreatitis are undertreated: a Dutch national survey. Pancreatology 12(1):71–73
Sikkens EC, Cahen DL, Koch AD, Braat H, Poley JW, Kuipers EJ, Bruno MJ (2013) The prevalence of fat-soluble vitamin deficiencies and a decreased bone mass in patients with chronic pancreatitis. Pancreatology 13(3):238–242
Singh VK, Haupt ME, Geller DE, Hall JA, Quintana Diez PM (2017) Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol 23(39):7059–7076
Slaff J, Jacobson D, Tillman CR, Curington C, Toskes P (1984) Protease-specific suppression of pancreatic exocrine secretion. Gastroenterology 87(1):44–52
Smith JL, Jiang CL, Hunt JN (1984) Intrinsic emptying pattern of the human stomach. Am J Phys 246(6 Pt 2):R959–R962
Stallings VA, Stark LJ, Robinson KA, Feranchak AP, Quinton H (2008) Evidence-based practice recommendations for nutrition-related management of children and adults with cystic fibrosis and pancreatic insufficiency: results of a systematic review. J Am Diet Assoc 108(5):832–839
Stein J, Jung M, Sziegoleit A, Zeuzem S, Caspary WF, Lembcke B (1996) Immunoreactive elastase I: clinical evaluation of a new noninvasive test of pancreatic function. Clin Chem 42(2):222–226
Struyvenberg MR, Martin CR, Freedman SD (2017) Practical guide to exocrine pancreatic insufficiency – breaking the myths. BMC Med 15(1):29
Trang T, Chan J, Graham DY (2014) Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency in the 21(st) century. World J Gastroenterol 20(33):11467–11485
Vanga RR, Tansel A, Sidiq S, El-Serag HB, Othman M (2018) Diagnostic performance of measurement of fecal elastase-1 in detection of exocrine pancreatic insufficiency – systematic review and meta-analysis. Clin Gastroenterol Hepatol 16(8):1220–1228.e4
Veeger RW, AbelsS J, Hellemans N, Nieweg HO (1962) Effect of sodium bicarbonate and pancreatin on the absorption of vitamin B12 and fat in pancreatic insufficiency. N Engl J Med 267:1341–1344
van Velzen D, Ball LM, Dezfulian AR, Southgate A, Howard CV (1996) Comparative and experimental pathology of fibrosing colonopathy. Postgrad Med J 72(Suppl 2):S39–S48
Weber AM, Roy CC, Chartrand L, Lepage G, Dufour OL, Morin CL, Lasalle R (1976) Relationship between bile acid malabsorption and pancreatic insufficiency in cystic fibrosis. Gut 17(4):295–299
White JV, Guenter P, Jensen G, Malone A, Schofield M (2012) Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enter Nutr 36(3):275–283
Acknowledgement
Dr. Graham is in part by the Research Service Department of Veterans Affairs and by Public Health Service grant DK56338 which funds the Texas Medical Center Digestive Diseases Center. The authors acknowledge the excellent advice received from Temitope Osinaiya, DHSc, MS, RD, LDN regarding the nutritional assessment of patients with pancreatic insufficiency.
Competing Interests
Dr. Graham is a consultant for RedHill Biopharma regarding novel H. pylori therapies and has received research support for culture of Helicobacter pylori and is the PI of an international study of the use of antimycobacterial therapy for Crohn’s disease. He is also a consultant for BioGaia in relation to probiotic therapy for H. pylori infection and for Takeda in relation to H. pylori therapies. Dr. Ketwaroo does not have any relevant disclosures.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Springer Nature Singapore Pte Ltd.
About this chapter
Cite this chapter
Ketwaroo, G.A., Graham, D.Y. (2019). Rational Use of Pancreatic Enzymes for Pancreatic Insufficiency and Pancreatic Pain. In: Labrou, N. (eds) Therapeutic Enzymes: Function and Clinical Implications. Advances in Experimental Medicine and Biology, vol 1148. Springer, Singapore. https://doi.org/10.1007/978-981-13-7709-9_14
Download citation
DOI: https://doi.org/10.1007/978-981-13-7709-9_14
Published:
Publisher Name: Springer, Singapore
Print ISBN: 978-981-13-7708-2
Online ISBN: 978-981-13-7709-9
eBook Packages: Biomedical and Life SciencesBiomedical and Life Sciences (R0)