Recognizing symptoms & clinical features of EPI

DR. RANNEY: So I'm really excited about being able to do this today. Pancreatic insufficiency is something that I see on a weekly basis. It is just so much more common than people think.

MELISSA: I agree. As an APP, it's so important to have everybody on your care team be aware of it and be able to talk comfortably about EPI so that we can really listen to our patients and get them to the treatment that they need.

DR. RANNEY: When assessing patients who present with symptoms related to EPI, it's important to bear in mind that the primary symptoms are diarrhea, gas, bloating, and abdominal pain and cramping. In the most severe forms of the disease, you can see steatorrhea and weight loss, but these features are not always present. I'm sure you see this too, but for many of our patients, it may take a while to arrive at a diagnosis since many of these symptoms overlap with how other GI conditions present.

MELISSA: Absolutely. We do see this and, yes, I think there is a lot of overlap. In my differential diagnosis, I always like to talk about foods that might aggravate their condition. I also want to know about their personal history, have they tried any over-the-counter treatments, any underlying conditions, have they noticed any unintentional weight loss? I think in addition to those questions, asking about the patient's family history is really important.

DR. RANNEY: Family history can help you rule out a number of conditions that may have a genetic predisposition—like celiac disease or Crohn's disease. So I'll often begin there, then I like to move onto their personal history to try to identify any risk factors that may increase their chance for having EPI. It's interesting that you start with diet. I think many clinical features of EPI are food-related, so I bet that helps you rule out EPI a lot faster.

MELISSA: Absolutely. I think rule out or diagnose, right? Symptoms related to food intake, like fatty stools, fecal urgency, unexplained weight loss; those are some of the big indicators that can make me consider that a patient might be experiencing EPI.

DR. RANNEY: Yeah, it's important to keep an open mind about the diagnosis from the start, and I think you do a really nice job of that when you collect the patient's medical and surgical history. I think it's critical to collect that information because it may not always be enough to make a diagnosis of EPI, but it can definitely key you in. And It's not just about the type of symptoms either. We need to assess the severity of those symptoms, how often patients are experiencing them, and when. For instance, if a patient with chronic pancreatitis tells me they're rushing to the bathroom and passing oily stools right after eating, that sets off warning bells in my mind that their symptoms could be from EPI.

DR. RANNEY: So, I'm curious: what is your approach to diagnosing EPI? Do you use a lot of diagnostic testing, like fecal elastase, to arrive at a diagnosis, or are you making a clinical diagnosis based on symptoms and risk factors?

MELISSA: I tend to do more on a clinical presentation. In general, I don't order the stool elastase test. I think if the patient is experiencing symptoms of EPI, and especially after ruling out other conditions in my differential diagnosis, then we as a team feel more confident that the issue is due to the pancreas and making that clinical diagnosis of EPI.

MELISSA: Once I suspect EPI, I'm usually quick to educate patients on the function of the pancreas, because if EPI goes untreated, patients may experience malabsorption, which could impact their overall health.

DR. RANNEY: Exactly. Within our practice, I know one of the first things that we talk about after diagnosing our patients with EPI are the consequences of delaying treatment, such as the malabsorption of fat. You know, I'll tell you, patients with EPI have often been suffering for a long time, and I think they're so relieved when the correct diagnosis is finally made. Most of our patients have been dealing with these symptoms for years, and oftentimes have been treated with other medicines or been diagnosed with other conditions, and obviously those things haven't helped, but we don't want to scare our patients with doom and gloom, so we reassure them that EPI can be managed.

DR. RANNEY: With CREON I explain that it contains enzymes that will break down their food to help with digestion. I also tell them that CREON has multiple dosing options. These options allow most patients to take two 36,000 unit capsules with a meal. And one 36,000 unit capsule with a snack, which is one of the reasons I choose to prescribe CREON.

SAFETY VOICE OVER:

Indication

CREON^® (pancrelipase) delayed-release capsules are indicated for the treatment of exocrine pancreatic insufficiency in adult and pediatric patients.

Important Safety Information

• Fibrosing colonopathy has been reported following treatment with pancreatic enzyme products. Do not exceed the recommended dosage of 2,500 lipase units/kg/meal (or 10,000 lipase units/kg/day) or 4,000 lipase units/g fat ingested/day in adult and pediatric patients greater than 12 months of age without further investigation.
• To avoid irritation of oral mucosa, care should be taken to ensure that CREON is not crushed, chewed, or retained in the mouth. CREON should always be taken with food.
• Pancreatic enzyme products contain purines that may increase blood uric acid levels. High dosages have been associated with hyperuricosuria and hyperuricemia. Consider monitoring blood uric acid levels in patients with gout, renal impairment, or hyperuricemia during treatment with CREON.
• There is theoretical risk of viral transmission with all pancreatic enzyme products, including CREON.
• Severe hypersensitivity reactions including anaphylaxis, asthma, hives, and pruritus have been reported with pancreatic enzyme products. Monitor patients with a known hypersensitivity reaction to proteins of porcine origin for hypersensitivity reactions during treatment with CREON.
• Adverse reactions that occurred in at least 2 cystic fibrosis patients (greater than or equal to 4%) receiving CREON were vomiting, dizziness, and cough.
• Adverse reactions that occurred in at least 1 chronic pancreatitis or pancreatectomy patient (greater than or equal to 4%) receiving CREON were hyperglycemia, hypoglycemia, abdominal pain, abnormal feces, flatulence, frequent bowel movements, and nasopharyngitis.

Please see the accompanying full Prescribing Information, including Medication Guide or visit https://www.rxabbvie.com/pdf/creon_pi.pdf