How I Treat--Exocrine Pancreatic Insufficiency
World Small Animal Veterinary Association World Congress Proceedings, 2008
Jörg M. Steiner, Dr.med.vet., PhD, DACVIM, DECVIM-CA
Gastrointestinal Laboratory, Dept. VSCS, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University
College Station, TX, USA

Enzyme Supplementation

Most dogs and cats with EPI can be successfully treated by dietary supplementation with pancreatic enzymes. Dried extracts of bovine or porcine pancreas are available (e.g., Viokase® or Pancrezyme®). The clinical impression in dogs and cats that powder is more effective than tablets, capsules, and especially enteric-coated products has also been substantiated in human patients with EPI. Initially, two teaspoons per 20 kg body weight and meal should be given in dogs and one teaspoon per cat and meal in cats. Oral bleeding has recently been reported in 3 of 25 dogs with EPI treated with pancreatic enzyme supplements.1 The oral bleeding stopped in all 3 dogs after the dose of pancreatic enzymes was decreased. Moistening the food pancreatic/powder mix also appears to decrease the frequency of this side effect.

If the owner has access to fresh pancreas this may be a viable alternative to use of pancreatic powder. However, there is a slight risk of transmission of Aujeszky's disease from raw pork pancreas, BSE from raw bovine pancreas, and Echinococcus from raw game pancreas. One to three ounces (30-90 g) of raw chopped pancreas can replace one teaspoon of pancreatic extract. Raw bovine pancreas can be kept frozen for several months without loss of enzymatic activity. Preincubation of the food with pancreatic enzymes, supplementation with bile salts, or concurrent antacid therapy are unnecessary in most canine and feline patients with EPI. When clinical signs have resolved the amount of pancreatic enzymes given can be gradually decreased to the lowest effective dose, which may vary from patient to patient, and from batch to batch of the pancreatic supplement.

Even though pancreatic enzyme supplementation causes the clinical signs to subside in almost all patients, it has been shown in human beings and dogs with EPI that nutrient absorption, and particularly fat absorption are not normalized by enzyme supplementation. This is thought to be due to the low pH in the stomach leading to irreversible damage of the pancreatic lipase contained in the supplement. Even though gastric pH can be raised by administration of antacids, the negative effect of the increased intraluminal gastric pH on fat digestion by gastric lipase appears to cancel much of the positive effect, so that overall there is only a minimal increase in fat absorption, which is clinically not important in most patients. However, the use of omeprazole has recently been shown to be efficacious in human patients with EPI and may be tried if the patient does not respond to routine therapy.

Dietary Considerations

Some authors have suggested feeding low fat diets in order to accommodate impaired fat digestion. However, this may even further decrease fat assimilation and may potentially lead to serious complications associated with hypovitaminoses of fat-soluble vitamins and conditions associated with a lack of essential fatty acids. Some types of dietary fiber interfere with pancreatic enzyme activity. Therefore, a diet low in insoluble or non-fermentable fiber should be fed.

Vitamin Supplementation

Response to enzyme supplementation alone may not be satisfactory in some canine or feline patients with EPI. This is not surprising if one considers that many dogs and especially cats with EPI also have a serious depletion of total body cobalamin stores. Serum cobalamin and folate concentrations should be routinely evaluated in small animals with suspected EPI, and dogs and cats with severely decreased serum cobalamin concentrations should be treated with cobalamin parenterally. Even though hypovitaminoses of other vitamins, especially vitamin K, are not very common, they have been reported in some cats with EPI and should be anticipated as potential complications.

Patients That Do Not Respond to Therapy

Some dogs and cats do not respond to enzyme supplementation and cobalamin application. These patients likely have concurrent small intestinal disease. In dogs with EPI small intestinal bacterial overgrowth is common and may need to be treated with antibiotic therapy. In cats with EPI inflammatory bowel disease can occur concurrently.

Prognosis

EPI is associated with an irreversible loss of pancreatic acinar tissue in most cases, and complete recovery is therefore extremely rare. However, with appropriate management and monitoring these patients usually gain weight quickly, pass normal stools, and can go on to live a normal life for a normal life span.

Reference

1.  Rutz GM, Steiner JM, Williams DA. Oral bleeding associated with pancreatic enzyme supplementation in three dogs with exocrine pancreatic insufficiency. J Am Vet Med Assoc 2002; 221:1716-1718.

Speaker Information
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Jörg M. Steiner, Dr.med.vet., PhD, DACVIM, DECVIM-CA
Gastrointestinal Laboratory Dept., VSCS College of Veterinary Medicine and Biomedical Sciences
Texas A&M University
College Station, Texas, USA


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