pancreatitis%20-%20chronic
PANCREATITIS - CHRONIC
Chronic pancreatitis develops from irreversible scarring sustained by the pancreas from prolonged inflammation.
Signs and symptoms include abdominal pain that is epigastric in location that radiates to the back and frequently occurs at night or after meals, symptoms of fat, protein & carbohydrates maldigestion that become apparent with advanced chronic pancreatitis and presence of diarrhea.
Chronic pancreatitis results in destruction of alpha and beta cells which gives rise to deficiencies of both insulin and glucagon.

Pharmacotherapy

Pancreatic Enzyme Supplements

  • Goal is to give at least 10% of normal pancreatic output w/ every meal
  • Non-enteric-coated preparations are preferred for the treatment of pain while enteric-coated preparations are used more frequently for the treatment of exocrine insufficiency
  • Action: Negative feedback inhibition of the pancreas
    • Administered enzymes denature CCK-releasing peptide which results in reduced CCK release
    • CCK release is thought to increase pancreatic pain
  • Because neural control also plays a role in controlling pancreatic secretion, suppression of secretion through this method is not complete & may be variable
  • Some studies have shown that response is generally poor in patients w/ advanced chronic disease or w/ significant abnormalities of the pancreatic duct (“big-duct” disease)
  • A trial of treatment may be beneficial for patients w/ less advanced disease who have failed more simple medical measures
  • Concomitant treatment w/ gastric acid-suppressing agents is recommended to avoid inactivation of non-enteric-coated pancreatic enzymes by gastric acid

Inhibitors of Gastric Acid Secretion

  • Action: Inhibition of acid secretion leads to a higher duodenal pH, which may in turn reduce pancreatic secretion & pain
  • Histamine2-receptor antagonists (H2RAs) & proton pump inhibitors (PPIs) may be used
  • There is no definite evidence showing the effectiveness of this therapy, but it is commonly tried due to its safety & ease of administration
  • Concomitant acid suppression is also recommended during therapy w/ non-enteric-coated pancreatic enzymes to prevent enzyme inactivation by gastric acid

Analgesics

  • Pain relief is a primary priority in the management of disease
  • Considered if pain was unresponsive to pancreatic enzyme supplementation
  • Non-narcotic agents may be tried initially
    • However, most patients need more potent agents for pain relief eg narcotics
    • Pregabalin or Gabapentin may be considered as adjuvant therapy if pain is unresponsive to narcotics
    • Pain medication should not be withheld even if there is concern regarding possible addiction
  • Goal of treatment is control of pain to a satisfactory or tolerable level rather than total elimination of pain

Antidepressants

  • Depression may lower the pain threshold of some patients
  • Pain may also have important psychiatric, psychosocial & psychosomatic components
  • Antidepressants, eg selective serotonin reuptake inhibitors or tricyclic antidepressants, may be used as adjunctive therapy to alleviate depression & to potentiate the effect of narcotics
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