Pancreatic enzyme replacement therapy in chronic pancreatitis: a long way to go

Pancreatic exocrine insufficiency (PEI) in chronic pancreatitis (CP) is underdiagnosed and undertreated. An important and expertly conducted meta-analysis in this issue examines the efficacy of pancreatic enzyme replacement therapy (PERT) in patients with CP.1 The key findings are that PERT increases fat and protein absorption and does so more effectively with higher dosing, enteric coating, administration with food and concomitant acid suppression. The follow-up studies indicated that PERT increases serum nutritional parameters, improves GI symptoms and quality of life without significant adverse events. While none of these findings are new, the study provides a higher level of evidence for them. The meta-analysis is important for several other reasons. First, only level 1 evidence is used (n=14 randomised controlled trials) for the quantitative analysis of fat absorption. Second, it counters the inconclusive Cochrane Review2 and should remove any lingering doubt about the efficacy of PERT in CP. Third, it is confined to CP and does not complicate things by attempting to address the more challenging questions about the role of PERT in other pancreatic diseases, after pancreatic …