Pankreatin

Question

Hello,
I would be interested in your opinion about the enzyme therapy of our pancreatic insufficient son.
He gets Kreon® in a dosage of 4000 untis per gram fat. However, he has often fat in the stool and gains weight awfully bad. How high can the dosage of Kreon® be? Would it make sense to test another preparation? Are there any preparations that contain additionally alkalizing substances in order to intensify the efficacy of the enzymes? Or should one give an anti-acid drug?
Many thanks!

Answer

[Preliminary remark: it has not been mentioned in the question, if your son suffers from CF or not. We assume, that he suffers from CF. The age of the son has not been mentioned either.]

Hello,
Many thanks for you question.
The units of lipase per gram fat are for sure sufficient. The age of your son is important for a judgement. One has of course to take into account, if the enzymes can develop their full potency in the small bowel. Has the acid degree of the stomach ever been measured? We have always to take into account an increased acidity of the stomach. The enzymes do not stand too much acid at all. They need a rather alkalic milieu. In order to increase the enzyme activity in such a case, the intake of a proton blocker is necessary, for example 20-40 mg of omeprazole in the mornings after getting up, depending on age and weight of the patient. This measure alone should lead to a better digestion of the fat. The orientating concentration for replacing pancreatic enzymes is at 10.000 units lipase / kg body weight. Primarily it does not make any sense to replace the preparation of the pancreatic enzymes. Kreon® belongs to the qualitatively best enzyme preparations. Therefore the alreday by you proposed antiacidic drug is actually the first step for a better enzyme effect.
The lack of weight gain can also be due to a consuming lung disease caused by an infection. Lung function / thorax x-ray and germ spectrum have to be supervised intensively.
Please discuss all further steps with your CF team or the treating physician.
Yours sincerely,
Dr. H.-E. Heuer

29.04.2014

29.4.14
Furthermore, the correct way of the enzyme intake is important.
Kreon® supplements the pancreatic enzymes in the galenic form of micropellets and they are saved in gelatine capsules. Micropellets are covered with an acid resistant coat, this film saves the enzymes from the acidic environment of the stomach. Via chewing of the Kreon® pellets, the natural acid protection of the enzymes is destroyed and therefore the effectiveness of the enzymes is lowered markedly. Therefore, for little children the gelatine capsules can be opened and the micorpellets should be mixed with a small amount of liquid (e.g. water, tea) or a small amount of food, like fruit purree. Mixing them with for example yoghourt will reduce the effectiveness of the enzymes.This mixture should be given from a spoon directly before the feed (and if necessary partly during the feed). The pellets should not be mixed with the entire amount of food.
Once in the intestine, the enzymes are active for about half an hour, after which they are broken down. It is therefore important not to take the whole dosage of enzymes at the beginning of the meal, but to spread the intake of enzymes over the meal, especially for patients who eat slowly. Should one forget to take pancreatic enzymes during the meal it is possible to take the enzymes shortly after the meal, but not more than half an hour after the meal.

Dr. D. d'Alquen (coordinator of the Central English Archive of ECORN-CF)