Accreditation/Credit Designation

Physicians’ Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Physicians’ Education Resource®, LLC, designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physicians’ Education Resource®, LLC, is approved by the California Board of Registered Nursing, Provider #16669, for 1.0 Contact Hour.

Acknowledgment of Commercial Support

This activity is supported by an educational grant from AbbVie Inc.

Advances in™ Exocrine Pancreatic Insufficiency: Breaking Down Diagnosis and Treatment

Release Date: December 20, 2019
Expiration Date: December 20, 2020
Media: Internet - based

Activity Overview

Exocrine pancreatic insufficiency (EPI) is a condition characterized by deficiency of the exocrine pancreatic enzymes amylase, lipase, and protease, resulting in the inability to digest food properly. This maldigestion, especially of fats is the main cause of weight loss in patients with EPI, and these patients present with low levels of micronutrients, fat-soluble vitamins, and lipoproteins. Together with abdominal cramps and the typical characteristics of fatty stools associated with steatorrhea the main clinical consequence of EPI is malnutrition. Consequently, individuals with EPI have a high morbidity and mortality secondary to an increased risk of malnutrition-related complications and cardiovascular events, as well as a potential decrease in quality of life. Unfortunately, a diagnosis of EPI is frequently underrecognized because the signs and symptoms overlap with other gastrointestinal diseases.

The Advances in™ Exocrine Pancreatic Insufficiency: Breaking Down the Diagnosis and Treatment of EPI activity will aid clinicians in earlier recognition of EPI with an overview of the clinical presentation and both pancreatic and nonpancreatic etiology. Expert faculty will then describe how a diagnosis is best made and then review the available treatments with practical strategies to optimize patient outcomes.

Benefits of Participating

  • Recognize when to consider EPI in patients with gastrointestinal and other overlapping symptoms
  • Build confidence in making a diagnosis of EPI using available laboratory and imaging tests
  • Learn strategies to effectively treat and manage patients with pancreatic enzyme replacement therapy

Acknowledgement of Commercial Support

This activity is supported by an educational grant from AbbVie Inc.

Instructions for This Activity and Receiving Credit

  • You will need to log in to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review Videos/content until you finish the presentation.
  • At the end of the activity, “Educational Content/Videos” will be available for your reference.
  • In order to receive a CME/CE Certificate, you must complete the activity.
  • Complete the Posttest and pass with a score of 70% or higher, complete the Evaluation, and then click on “Request for Credit.” You may immediately download a CME/CE Certificate upon completion of these steps.

Target Audience

This online educational activity is directed toward gastroenterologists, primary care physicians, and additional healthcare professionals involved in patient care for prevention and treatment of EPI, such as nurse practitioners and physician assistants.

Learning Objectives

Upon successful completion of this educational activity, you should be better prepared to:

  • Analyze the epidemiology, etiology, and pathophysiology of exocrine pancreatic insufficiency (EPI)
  • Review the key aspects of an EPI diagnosis including physical exam, indirect and direct pancreatic function test findings
  • Evaluate the efficacy, safety, and indications of the available PERT therapies for patients with EPI

Faculty, Staff, and Planners’ Disclosures

Faculty

Andres Gelrud
Andres Gelrud, MD, MMSc
Director
Pancreatic Disease Center
Gastro Health and Miami Cancer Institute
Miami, FL

Disclosures: Consultant: AbbVie; Speaker’s Bureau: AbbVie.

The staff of Physicians' Education Resource®, LLC (PER®) have no relevant financial relationships with commercial interests to disclose.

Disclosure Policy and Resolution of Conflicts of Interest (COI)

As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME/CE activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME/CE activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.

Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only and is not meant to substitute for the independent clinical judgment of a physician and nurse relative to diagnostic or treatment options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of PER® or the company that provided commercial support.

PER Pulse&trade Recaps

1 of 3

In a recent CME-certified activity, Andres Gelrud, MD, MMSc, described presenting symptoms and causes of exocrine pancreatic sufficiency, and outlined commonly used indirect tests for diagnosis. He then provided practical insights for individualizing treatment with pancreatic enzyme replacement therapy.

This first of 3 PER Pulse™ Recaps focuses on the etiology of exocrine pancreatic insufficiency (EPI).

EPI, characterized by a deficiency of enzymes essential for the digestion of fats, occurs when intraduodenal levels of lipase fall below 10% of normal enzyme output.1 The main consequence of this malabsorption is malnutrition, with symptoms including abdominal cramps and steatorrhea.2 Although patients typically present with low circulating levels of micronutrients, fat-soluble vitamins, and lipoproteins, the clinical presentation of EPI is highly variable, depending on the underlying cause, stage of disease, diet, and other factors.2,3

The etiology of EPI has both pancreatic and nonpancreatic causes:2

  • EPI is most commonly associated with diseases that damage the pancreatic parenchyma, including:
    • Chronic pancreatitis, with an incidence ranging from 30% in mild cases to 85% in more severe disease.4
    • Cystic fibrosis, with approximately 85% of infants presenting with EPI at birth.5
    • Pancreatic resection.2
  • EPI frequently occurs in all types of diabetes.2
  • Gastrointestinal causes of EPI include celiac disease, Crohn disease, inflammatory bowel disease, Zollinger-Ellison syndrome, and gastrointestinal surgical resections.2,3

“The pancreas has a very big functional reserve; up to 80% or 90% percent of the gland needs to be severely injured or malfunctioning for patients to develop steatorrhea. Typically, patients come to you because they may be losing weight, they tell you they’re eating and still losing weight. That should be a major red flag that the patient may have exocrine pancreatic insufficiency. Or they may tell you that soon after they eat, they frequently have to go to the bathroom. They tell me that they had a late dinner and then they wake up with the urge to move their bowels. That’s very, very unusual.”

-Andres Gelrud, MD, MMSc

References

  1. DiMagno EP et al. N Engl J Med. 1973;288(16):813-815.
  2. Singh VK et al. World J Gastoenterol. 2017;23(39):7059-7076.
  3. Domínguez-Muñoz JE. Adv Med Sci. 2011;56(1):1-5.
  4. Hart PA et al. Curr Treat Options Gastroenterol. 2015;13(3):347-353.
  5. Van de Vijver E et al. J Pediatr Gastroenterol Nutr. 2011;53(1):61-64.

2 of 3

This second of 3 PER Pulse™ Recaps focuses on the diagnosis of exocrine pancreatic insufficiency (EPI).

The diagnosis of EPI is complicated by overlapping symptoms with more common gastrointestinal disorders and by the less severe symptoms early in the disease. Although the coefficient of fat absorption, via a 72-hour fecal fat analysis, is considered the gold standard for diagnosis, the indirect testing of fecal elastase-1 (FE-1) is more practical and commonly used.1,2

  • FE-1 levels of less than 200 ug/g is the cutoff for diagnosis of EPI.3
    • Watery stool samples may result in a false positive.2
    • Pancreatic enzyme replacement therapy does not affect FE-1 levels.3
  • Direct pancreatic tests, based on hormonal stimulation of the pancreas, allow for increased sensitivity when EPI is suspected early on in the disease process or in mild or severe cases.4
  • Measurement of nutritional markers such as the fat-soluble vitamins, prealbumin, albumin, and magnesium provide additional diagnostic support.5

“Oftentimes these patients will present over and over again to emergency care and urgent care facilities and be worked up for abdominal pain. Nothing is found. Sometimes they will have an exploratory surgery to see what’s causing this recurring problem. The swelling may be allergic, so they go to an allergist who says, ‘well, maybe it’s a food allergy or something else.’ It’s a very difficult diagnosis because it can present in a variety of different ways.”

-Andres Gelrud, MD, MMSc

References

  1. Singh VK et al. World J Gastoenterol. 2017;23(39):7059-7076.
  2. Struyvenberg MR et al. BMC Med. 2017;15(1):29.
  3. Forsmark CE. Chronic pancreatitis. In: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 10th ed. 2016:1020.
  4. Hart PA et al. Curr Treat Options Gastroenterol. 2015;13(3):347-353.
  5. Lindkvist B. World J Gastroenterol. 2013;19(42):7258-7266.

3 of 3

This third of 3 PER Pulse™ Recaps focuses on pancreatic enzyme replacement therapy (PERT).

Pancrelipase formulations provide safe and effective therapy for treating pancreatic exocrine insufficiency.1 Several formulations are available, each with varied concentrations of lipase, protease, and amylase for individualizing treatment based on patient response.2 Patient education is key to the success of therapy with an emphasis on adherence and timing of daily dosing with all meals and snacks.

Additional factors to consider in PERT:

  • Doses are based on body weight and should be adjusted to the fat content of each meal.3
  • Response to treatment can be assessed by weight gain and improvement in symptoms.2
  • Lifestyle modifications including smoking cessation and abstinence of alcohol are critical, as both can be detrimental to treatment success.1

“I tell patients not to miss the medication and to take it at the right time. I usually tell them to take a dose in the middle of the meal or just at the beginning of the meal, and then a second dose at the end of the meal and one with snacks. And this is very important to emphasize, particularly at the start of therapy, when they are more motivated to take the treatment and to do it correctly, because when they do it correctly, when they come back a month later, they are going to be gaining weight. The sensation of well-being, it’s going to be there. They’re going to have more energy because a lot of the food and nutrients that were being wasted, now they’re being absorbed.”

-Andres Gelrud, MD, MMSc

References

  1. Brennan GT et al. JOP. 2019;20(5):121-125.
  2. Forsmark CE. Chronic pancreatitis. In: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 10th ed. 2016:1020.
  3. Borowitz DS et al. J Pediatr. 1995;127(5):681-684.

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