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U.S. pancreatic insufficiency patients often get inadequate enzyme replacement



A majority of U.S. patients with presumed exocrine pancreatic insufficiency are likely going undiagnosed and untreated, and even those who get enzyme replacement therapy often receive too little, according to a recent analysis of insurance claims data from more than 48 million Americans.

Amid concerns that some people with nonspecific symptoms are overdiagnosed with exocrine pancreatic insufficiency (EPI) and hence getting unneeded treatment with pancreatic enzyme replacement therapy (PERT), it seems like substantial numbers of patients with legitimate pancreatic morbidity are often missed and are going untreated, Chris E. Forsmark, MD, said at the annual Digestive Disease Week®. This includes patients with chronic pancreatitis, pancreatic cancer, and patients who underwent pancreatic resection surgery.

Dr. Chris E. Forsmark, professor of medicine, University of Florida, Gainesville Mitchel L. Zoler/MDedge News

Dr. Chris E. Forsmark

“We are giving too little” PERT to patients with high-risk conditions, said Dr. Forsmark, professor of medicine and chief of gastroenterology, hepatology, and nutrition at the University of Florida, Gainesville. Not only are high-risk patients often undiagnosed with EPI, but even those who are diagnosed and get PERT frequently receive less than the minimally effective dosage. “Education of patients and providers is needed to improve the appropriate use of PERT,” he concluded.

Dr. Forsmark cited still-unpublished evidence that he has reported at meetings during the past year. At DDW 2017 he and his associates reported findings from an analysis of health insurance claims data collected in the PharMetrics database for more than 48 million Americans during 2006-2013, which included 37,061 insured adults diagnosed with chronic pancreatitis. Analysis of these data showed that just 7% had ever undergone testing for EPI and 30% had received a prescription for PERT, of which only 31% received an appropriate dosage (Gastroenterology. 2017 Apr;152[5, suppl 1]:S677). In other words, a scant 9% of insured U.S. adults with chronic pancreatitis during the studied period had received a minimally effective dosage of PERT.

Dr. Forsmark and his associates ran a second analysis using the same 2006-2013 insurance database, but this time looked at 32,461 insured American adults diagnosed with pancreatic cancer and reported similar findings: Fewer than 2% of patients underwent testing for EPI, 22% were prescribed PERT, and of these, 22% of patients per quarter received a minimally effective dosage of PERT, meaning that, overall, only 6% of pancreatic cancer patients received treatment that could be expected to resolve their presumed enzyme deficiency. Dr. Forsmark and his associates presented this report at the annual meeting of the American Pancreatic Association in San Diego in November 2017 (Pancreas. 2017 Nov/Dec;46[10]:1386-1448).

An irony is that PERT underuse comes at a time when some Internet sites promote PERT as a treatment for patients with nonspecific symptoms of EPI such as bloating, dyspepsia, and loose stools, Dr. Forsmark noted. “There is a possibility that patients with nonspecific gastrointestinal symptoms may request or receive PERT. Some patients may receive PERT who do not have EPI.” In 2015, clinicians had written roughly 746,000 prescriptions for PERT to U.S. patients, with the number of prescriptions steadily increasing during 2010-2015. Five different formulations for PERT are currently on the U.S. market, and a typical course of treatment costs about $1,500-$2,000 per month, he added.

Dr. Forsmark had no disclosures to report.

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