1.9 Drugs affecting intestinal secretions
Pancreatin is recommended for replacement therapy in pancreatic enzyme deficiency states. Pancreatin is inactivated by gastric acid. Two formulations are available.
Creon® 10 000 and the higher strength preparation 25 000 (capsules) contain enteric-coated pellets. The capsules may be swallowed whole or the contents of the capsule mixed with fluid or soft food. The pellets should not be chewed as this destroys the enteric coating. As with all pancreatic supplements, Creon®, especially at a high dosage, may cause perianal irritation.
Pancrex V® (capsules, tablets, forte tablets) is a cheaper alternative, but large quantities of tablets are frequently required. The contents of Pancrex V® capsules are not enteric-coated and, when sprinkled on food, are less palatable than Creon®. Pancrex V® may cause local irritation if retained in the mouth.
Ursodeoxycholic acid (available as Destolit® 150mg tablets and Ursofalk® 250mg capsules) is used to dissolve cholesterol gall stones as an alternative to surgery. It is also used in the treatment of patients with primary biliary cirrhosis. Hospital supervision is required.
PRESCRIBING POINTS FOR DRUGS AFFECTING INTESTINAL SECRETIONS
- With the exception of Creon® 25 000, high-strength pancreatin preparations have been associated with reports of colonic strictures in children aged between 2 and 13 years. The CSM has recommended that;
- Pancrease HL®, Nutrizym 22® should not be used in children with cystic fibrosis aged 15 years or less
- The total dose of pancreatic enzyme supplements used in patients with cystic fibrosis should not usually exceed 10,000 units of lipase per kg body weight daily
- If a patient on any pancreatin preparation develops new abdominal symptoms (or any change in existing abdominal symptoms) the patient should be reviewed to exclude the possibility of colonic damage.
- Ensure adequate hydration at all times in patients taking higher-strength pancreatin preparations.
- The aim of treatment with pancreatic supplements is to control steatorrhoea and promote growth or weight gain. Treatment is adjusted to suit individual need.
- As well as being used to treat malabsorption in patients with pancreatic exocrine deficiency, supplements are also used in an attempt to treat the pain of chronic pancreatitis, whether or not it is associated with steatorrhoea. Their efficacy in this is not well proven. [Unlicensed indication].
- Pancreatin is inactivated by gastric acid and so high doses are required. Adding an antisecretory drug, such as an H2-receptor antagonist, may help patients unresponsive to high doses of pancreatin.
- Pancreatin is inactivated by heat and so care is needed if preparations are mixed with food or drink.