Chronic Pancreatitis Requires Early, Long-Term Care

KEY BISCAYNE, Fla?Chronic pancreatitis is an irreversible condition characterized by pancreatic insufficiency for which there is no cure. It is most often associated with excessive alcohol use, and is often not recognized in its early stages, noted presenters at the 16th Annual Advances and Controversies in Clinical Nutrition seminar of the Mayo Clinic College of Medicine. ?

"It is important for physicians to recognize this condition, treat it early, and always follow the patients, because they need long-term care," says Massimo Raimondo, MD, associate professor of medicine, Mayo Clinic, Jacksonville, Fla.

In the United States the disease is alcohol-related in up to 80% of patients. Most of the remaining cases are of the idiopathic type, with an early (age <35 years) or late (>50 years) onset. Although the etiology is unknown, a genetic disposition is involved in the early-onset group.

A common manifestation, particularly in those with alcohol addiction, is nutrient malabsorption. If left untreated, the patient will continue to malabsorb fat, lose weight, have problems with imbalances, develop low self-esteem, and be unable to lead a normal life. Chronic pancreatitis is not life threatening, but many patients do not live as long as their age-matched peers in the general population.

The healthy pancreas empties digestive secretions into the intestine after each meal. Once damaged, the pancreas does not have the capacity to heal itself; it atrophies and is essentially replaced by fibrous connective tissue. In addition, when the pancreas stops producing insulin, it must be replaced by medical therapy.?

Treatment consists of medications that supplement the digestive enzymes no longer produced by the pancreas. "By giving drugs, we are attempting to replace one of the functions of the pancreas, which is to correct malnutrition and malabsorption," said Dr Raimondo.

The drugs that take over the function of the pancreas contain enzymes that have been obtained from pigs. These enzymes must be tailored to the individual patient. They mix with the patient's food and act in the gut, stomach, and small intestine (particularly the duodenum and jejunum) to facilitate the digestion of nutrients. The medications are not absorbed; they work locally in the lumen, like the pancreatic enzymes. Ultimately, they are eliminated with the stool.

Dr Raimondo told IMWR that treatment choices are limited, and "the preparations currently available on the market are from porcine pancreases." One of the treatments currently in early stages of clinical trials "is a new lipase that has been obtained by genetic engineering from Pseudomonas glumae [now known as Burkholderia glumae], which is present in postprandial concentrations of bile acid. It looks like it is an ideal lipase." If proved appropriate for adults with chronic pancreatitis, "it will revolutionize the treatment for the disease."

This oral drug, ALTU-135 (Altus Pharmaceuticals), is an enzyme replacement therapy for patients with malabsorption caused by pancreatic insufficiency. The only known adverse effects are colonic strictures.