Restitution of normal fat absorption in
exocrine pancreatic insufficiency remains an elusive goal. Although many patients achieve satisfactory clinical results with
enzyme therapy, few experience normalization of fat absorption, and many, if not most, will require individualized
therapy. Increasing the quantity of
lipase administered rarely eliminates
steatorrhea but increases the cost of
therapy. Enteric coated
enzyme microbead formulations tend to separate from nutrients in the stomach precluding coordinated emptying of
enzymes and nutrients. Unprotected
enzymes mix well and empty with nutrients but are inactivated at pH 4 or below. We describe approaches for improving the results of
enzyme therapy including changing to, or adding, a different product, adding non-enteric coated
enzymes, (e.g., giving unprotected
enzymes at the start of the meal and
acid-protected formulations later), use of antisecretory drugs and/or
antacids, and changing the timing of
enzyme administration. Because considerable
lipid is emptied in the first postprandial hour, it is prudent to start
therapy with enteric coated
microbead prior to the meal so that some
enzymes are available during that first hour. Patients with hyperacidity may benefit from adjuvant antisecretory
therapy to reduce the duodenal
acid load and possibly also
sodium bicarbonate to prevent duodenal acidity. Comparative studies of clinical effectiveness of different formulations as well as the characteristics of dispersion, emptying, and dissolution of enteric-coated
microspheres of different diameter and density are needed; many such studies have been completed but not yet made public. We discuss the history of pancreatic
enzyme therapy and describe current use of modern preparations, approaches to overcoming unsatisfactory clinical responses, as well as studies needed to be able to provide reliably effective
therapy.