Management of comorbidities

How is EPI managed?

Exocrine pancreatic insufficiency (EPI) is managed with oral pancreatic enzymes, a specialized diet (low-fat, high-protein), and nutritional supplements when needed.

What is pancreatic enzyme replacement therapy?

This refers to the use of prescription oral medications that contain pancreatic enzymes:

• Lipase: works along with bile to help break down fats
• Amylase: breaks down starchy foods and complex carbohydrates into absorbable simple sugars
• Protease: breaks down protein in food and protects you from bacteria and yeast found in your intestines

Oral pancreatic enzymes replace the digestive enzymes the pancreas no longer produces. These enzymes facilitate nutrient absorption and reduce EPI symptoms. PERT medication contains a mixture of enzymes extracted from pig pancreas and is given in the form of capsules or tablets.

How to take pancreatic enzymes?

Take pancreatic enzymes with each meal or snack. Swallow the capsules whole with a cold drink and spread doses throughout your meals. Doses are adjusted by weight, meal size, and fat content, under medical guidance.

The doctor may prescribe you medicines that lower stomach acid (e.g., esomeprazole, omeprazole) to improve the effectiveness of some pancreatic enzymes.

Side effects

Most people tolerate pancreatic enzymes well. Possible side effects include constipation, stomach pain, gas, nausea, or diarrhea. Rarely, it may cause mouth irritation if not swallowed properly or allergic reactions in those sensitive to pork products. Improper dosing may lead to persistent symptoms rather than side effects.

Available pancreatic enzymes

Currently there are six FDA approved PERT medications which are available:

• CREON® capsules
• Pancreaze® capsules
• Pertzye® capsules
• Viokace® capsules
• Zenpep® capsules
• Ultresa® capsules

Supplements sold in drug stores without prescription are not regulated by the FDA, so they may not contain consistent or reliable amounts of pancreatic enzymes. This means the quality and effectiveness of these products are not guaranteed.

Oral medications for diabetes

The management of type-3c diabetes due to pancreatitis differs from the management of type-2 and type-1 diabetes. Some of the oral anti-diabetic that are used include:

• Metformin is commonly used and helps reduce blood glucose by decreasing the liver's glucose production and help the muscles use insulin better. It is usually taken twice daily. A common side effect is diarrhea, which often improves when taken with food.
• Sulfonylureas like glimepiride (Amaryl), glipizide (Glucotrol), and glyburide (Diabeta) work by stimulating the remaining insulin-making cells in the pancreas to release insulin. They are taken one to two times a day before meals. These medications can cause low blood sugar (hypoglycemia) and weight gain.

Insulin

Insulin becomes necessary when the pancreas can no longer produce enough insulin. There are various types of insulin, and your healthcare provider will help determine the most appropriate one based on your lifestyle, blood sugar patterns, and nutritional status.

Some patients may require a combination of insulins or a premixed insulin to achieve stable control.

Management of diabetic-associated complications

Patients with diabetes can develop complications, which require additional treatment:

• Neuropathy (nerve pain) can cause burning, tingling, or numbness in the hands and feet. Gabapentin or pregabalin are often prescribed to relieve this nerve pain
• Diabetic gastroparesis is a condition where the stomach empties too slowly due to nerve damage. It can cause nausea, bloating, and fullness. Management includes eating smaller, low-fat, low-fiber meals and sometimes using medications that stimulate stomach motility. Sometimes this can be treated endoscopically with a novel procedure called gastric peroral endoscopic myotomy (G-POEM)

Resources:

• American diabetes association

General recommendations

• Eat small, frequent meals instead of large ones to avoid feeling overly full
• Avoid high-fat or spicy foods, which can slow digestion or irritate your stomach
• Stay upright after eating for at least 1–2 hours to help food move through your stomach
• Sip clear fluids slowly, such as water, ginger tea, or electrolyte drinks, to stay hydrated

Medication for nausea

Antiemetics and prokinetics (a prokinetic is a medication that helps to move food through the stomach and intestines) are the mainstay of treatment. Drug choice and dose depends on symptoms, side effect profile, and availability:

• Ondansetron (Zofran®): Commonly used to treat nausea, especially when it comes on suddenly. It's usually well tolerated but can cause constipation in some people
• Metoclopramide (Reglan®): This medicine helps your stomach empty food more quickly and also helps with nausea. It can be taken as a pill or through an IV. Some people may feel restless or have muscle stiffness as side effects
• Prochlorperazine (Compazine®): Helps control nausea and vomiting, especially when symptoms are strong. It may make you feel sleepy or dizzy
• Erythromycin: An antibiotic that also helps your stomach move food. It works best for short-term use and may cause stomach discomfort if the dose is too high

First Steps to Manage Constipation

It's important to understand that having a bowel movement every day isn't necessary. The goal is to feel better, pass stools more easily, and reduce symptoms like bloating or straining.

• Eat more fiber: Include fruits (especially prunes, pears, and kiwi), vegetables, legumes, and whole grains. Increase fiber slowly to prevent bloating
• Drink plenty of fluids: Aim for at least 1.5 liters (6–8 cups) of water a day
• Be active: Gentle physical activity, like walking, helps your intestines move
• Bathroom habits: Try to go to the bathroom at the same time each day, especially after meals. Use a small stool to raise your feet when sitting on the toilet, this helps stool pass more easily

Fiber supplementation

Fiber supplementation can be considered for patients who are not able to achieve fiber goals with whole foods. Options for supplementation include concentrated dietary sources of fiber, such as bran, or bulk-forming laxatives.

Bulk-forming laxatives absorb water in the intestines and increase the bulk of your stool, which helps trigger natural movement of the bowel. Some include:

• Psyllium – Metamucil
• Methylcellulose – Citrucel
• Calcium polycarbophil – FiberCon
• Wheat dextrin – Benefiber

Fiber supplementation works best when taken with enough water. They are not recommended for people with very slow bowel movements (less than 3 per week), as they can worsen symptoms in those cases.

Laxatives

If lifestyle changes are not enough, laxatives can help. They are divided into two main types based on how they work:

Osmotic laxatives

These laxatives work by drawing water into the bowel, softening the stool and making it easier to pass. Some examples of osmotic laxatives include:

• Polyethylene glycol (PEG 3350) – MiraLAX
• Lactulose – Enulose
• Magnesium hydroxide – Milk of Magnesia
• Magnesium citrate – Citroma
• Sorbitol

Stimulant laxatives

These laxatives help the muscles of your colon contract more strongly to push stool through. Some examples of stimulant laxatives include:

• Bisacodyl – Dulcolax
• Senna – Senokot
• Sodium picosulfate – Pico-Salax (less commonly used in the U.S.)

Some common effects of laxatives include abdominal bloating, cramping and flatulence especially at high doses. These laxatives are generally well-tolerated but should be used with caution in people with kidney or heart problems.

Suppositories and Enemas

Suppositories are usually reserved for patients with severe symptoms where oral laxatives are not enough. While enemas are reserved for patients with fecal impaction, meaning that stool is "stuck" near the rectum. Some examples of suppositories and enemas include:

Suppositories:

• Glycerin suppositories: Soften stool and stimulate movement
• Bisacodyl suppositories – Dulcolax

Enemas:

• Tap water enemas: Safe for occasional use
• Avoid sodium phosphate enemas (e.g., Fleet), especially if you have kidney problems or are older, due to risk of serious side effects