A recently published randomized, double-blind, placebo-controlled trial in chronic pancreatitis patients has shown the significant therapeutic efficacy of these modern enzyme preparations

in reducing fat excretion, decreasing stool frequency and improving stool consistency.16 These results have been confirmed by means of the 13C-MTG breath test, analysis of coefficient of fat absorption and nutritional status in a recent prospective study including 49 patients with fat maldigestion secondary to chronic pancreatitis.6 Similar efficacy was shown in a placebo-controlled trial in patients suffering from cystic fibrosis with pancreatic exocrine insufficiency and steatorrhea.17 Despite the use of modern enteric-coated enzyme preparations in minimicrospheres,

fat digestion cannot revert to normal in almost half of the patients with pancreatic exocrine insufficiency.18 Inadequate patient compliance, low dose Epacadostat of enzymes, acidic intestinal pH and intestinal bacterial overgrowth are among the factors hampering total elimination of steatorrhea in this clinical setting.19 Patient compliance is a key factor in the management of pancreatic exocrine insufficiency with oral pancreatic enzymes. Patients should understand the importance of the therapy and the correct administration schedule.15 In addition, the prescribed dose of enzymes should be high enough, and a minimum dose of 40 000–50 000 Eur. Pexidartinib order Ph. U of lipase per meal is required.7,8 MCE The abnormally low pancreatic

secretion of bicarbonate in patients with pancreatic exocrine insufficiency is associated with a limited buffering effect in the proximal intestine. A pH below 4 is associated with an irreversible inactivation of endogenous and uncoated exogenous pancreatic lipase, as well as with precipitation of bile salts, contributing to fat maldigestion.20 In addition, enteric-coated pancreatic enzymes require a pH > 5 to be released, which may first occur in distal segments of the small intestine, thus reducing the efficacy of the therapy.21 Up to 40% of patients with pancreatic exocrine insufficiency secondary to chronic pancreatitis have concomitant intestinal bacterial overgrowth.22 This is probably due to a defect in the interdigestive “house keeper” function of gastrointestinal motility and biliopancreatic secretion. In fact, patients with chronic pancreatitis have been shown to lose the physiological synchrony between the interdigestive gastrointestinal motility and pancreatic secretion. These, together with a markedly low pancreatic secretion of enzymes, may favor the development of bacterial overgrowth.23 The first step to guarantee an optimal efficacy of oral pancreatic enzymes in the management of pancreatic exocrine insufficiency is to confirm the proper use of enzymes by patients.