Differentiated approach to replacement therapy in exocrine pancreatic insufficiency

The article is an overview of current ideas about indications and features of various enzyme preparations (EP). The following requirements are applied for all EP: nontoxicity, resistance to hydrochloric acid and pepsin, good tolerance by patients, no significant side effects, optimal effect at pH≈6.0, rapid release of enzymatic activity in the small intestine at pH≈6.0, while maintaining this activity no less than 2 hours, high enzyme activity, compliance with the composition stated on the label, high serial homogeneity of the preparation, no unpleasant odor and taste. Considering the variety of pathogenetic mechanisms and nosological units that occur with maldigestion and malabsorption syndromes, the spectrum of indications for EP is rather wide: pancreatic, liver, gall bladder diseases, preparation for instrumental studies, etc. The authors present a modern algorithm (“steps”) of enzyme therapy. A differentiated approach to the choice of EP is developed depending on the pathology that the patient suffers from, EP composition, and features of its action. Attention is drawn to the possible reasons for the lack of effectiveness of replacement therapy, general contraindications to the prescription of EP (acute pancreatitis, severe exacerbation of chronic pancreatitis, hypersensitivity to the drug components) and their individual components (bile acids, nicotinamide, activated charcoal). Complications of enzyme replacement therapy are indicated, namely: pain in the oral cavity; skin irritation in the perianal region; abdominal discomfort; nausea; fibrosing colopathy; allergic reactions; sometimes hyperuricosuria; pancreatin shaping complexes with folic acid, disrupting its absorption.