This retrospective cohort study evaluated whether an electronic medical record (EMR) best practice alert and smart set could improve diagnosis and management of exocrine pancreatic insufficiency (EPI) in high-risk patients, including those with chronic pancreatitis, pancreatic ductal adenocarcinoma, prior pancreatic resection, or EPI. Before implementation, the study identified multiple care gaps: only 57.2% of eligible patients were prescribed pancreatic enzyme replacement therapy, and among those receiving enzymes, only 61.9% were on a minimum therapeutic dose. Screening and monitoring were also inconsistent, with relatively low ordering rates for pancreatic elastase, vitamin D, A1c, DEXA scans, and documentation of metabolic bone disease.

After the best practice alert and smart set were implemented, the proportion of patients on a minimum therapeutic enzyme dose increased significantly, along with ordering of pancreatic elastase, vitamin D testing and supplementation, A1c, DEXA scans, and recognition of metabolic bone disease. However, the overall proportion of patients prescribed enzymes did not change, likely because the alert was limited to patients already on pancreatic enzyme replacement therapy (PERT) or when PERT was being prescribed, meaning some high-risk undiagnosed patients were missed. The authors conclude that EMR-based tools can be a low-cost, durable way to improve EPI care patterns, but further work is needed to improve earlier diagnosis, broader screening, and optimized treatment in high-risk groups.

Reference: Ladna M, Madhok I, Bhat A, et al. Impact of Order Set on Exocrine Pancreatic Insufficiency in Chronic Pancreatitis, Pancreatic Cancer, and Pancreatic Resection. Gastro Hep Adv. 2024 Aug 30;4(1):100541. doi: 10.1016/j.gastha.2024.08.019. PMID: 39790244; PMCID: PMC11713485.

This review explains how exocrine pancreatic dysfunction (EPD) exists on a spectrum, with the more severe form classified as exocrine pancreatic insufficiency (EPI). Because steatorrhea may not become clinically apparent until more than 90% of pancreatic enzyme-producing capacity is lost, milder EPD may present with nonspecific symptoms such as bloating and flatulence. The authors emphasize that suspected EPD can present in a wide range of ways and that non-pancreatic causes should be considered in the differential diagnosis, including celiac disease, Crohn’s disease, gastric/foregut surgery, diabetes mellitus, cholestatic disorders, medications, infections, and bacterial overgrowth. FE-1 is commonly used in evaluation, but results should be interpreted cautiously, particularly with watery stool and in patients with low pre-test probability.

Management depends on confirming the severity and cause of EPD. Patients with confirmed EPI generally need pancreatic enzyme replacement therapy (PERT), typically taken with meals and titrated based on symptoms, dietary fat/protein intake, and evidence of malabsorption. The review highlights practical pitfalls, including under-testing high-risk patients, prescribing PERT without confirming EPI, poor timing of enzymes with meals, inadequate dose titration, and anchoring on a low fecal elastase result without considering false lows or non-pancreatic causes. It also notes key clinical clues, such as fat-soluble vitamin deficiencies or calcium oxalate kidney stones, which may suggest severe fat malabsorption or undertreated EPI. Overall, the article argues for more accurate diagnosis, thoughtful differential assessment, and individualized PERT use rather than reflexive lifelong enzyme therapy for every patient with GI symptoms.

Reference: Ramsey ML, Hart PA, Forsmark CE. Evaluation and management of exocrine pancreatic insufficiency: pearls and pitfalls. Curr Opin Gastroenterol. 2023 Sep 1;39(5):428-435. doi: 10.1097/MOG.0000000000000951. Epub 2023 May 11. PMID: 37530731; PMCID: PMC10403264.

This retrospective population-based study examined whether pancreatic enzyme replacement therapy (PERT) dosing was associated with skeletal muscle loss during first-line chemotherapy in patients with advanced pancreatic cancer. Among 210 patients in Alberta, Canada, 81 were PERT users and were categorized as low or high dose based on estimated consumed daily dose. Muscle loss was common overall, but it was highest in the low-dose PERT group: 88% experienced CT-defined skeletal muscle loss, compared with 58% in the high-dose PERT group and 67% in the no-PERT group. After adjustment for disease stage, chemotherapy regimen, and tumor response, low-dose PERT was associated with 5.4-fold greater odds of muscle loss compared with high-dose PERT.

The findings suggest that undertreated exocrine pancreatic insufficiency (EPI) may contribute to muscle loss in advanced pancreatic cancer and that simply prescribing PERT may not be enough if the dose is too low or not used consistently. Patients in the low-dose group were initially prescribed lower doses, consumed less than prescribed, and were less likely to refill their prescriptions. Higher-dose users appeared better able to preserve skeletal muscle at rates closer to patients without clinical indications for EPI. The authors conclude that adequate PERT dosing, patient support, and provider education should be prioritized when EPI is suspected, while future prospective studies should measure actual PERT use, symptoms, intake, quality of life, and barriers to optimal dosing.

Reference: Klassen PN, Mazurak VC, Baracos V, et al. Dose optimization of pancreatic enzyme replacement therapy is essential to mitigate muscle loss in patients with advanced pancreatic cancer and exocrine pancreatic insufficiency. Clin Nutr. 2024 Aug;43(8):1900-1906. doi: 10.1016/j.clnu.2024.06.037. Epub 2024 Jul 4. PMID: 38991415.