1. Use of pancreatic enzymes to improve patient wellbeing - case study examples Gina Giebner Macmillan Dietitian Yeovil District Hospital 15 th May 2015 georgina.giebner@ydh.nhs.uk

2. Aim Highlight the role of Pancreatic Enzyme Replacement Therapy (PERT) in symptom management and improved patient reported outcomes

3. Case Study Mr E Mr E 70yr old Diagnosed with T4N0M0 Pancreatic head cancer (not able to resect) – confirmed biopsy 15.07.2014 Metal Stent placed 10.06.2014 for biliary obstruction (symptoms of itching, pale stools and diarrhoea pre stent) For palliative chemotherapy Post stent minimal malabsorption symptoms

4. Referral to dietitian and seen 24.07.2014 Diet controlled diabetic, wt 108kg, BMI 38, trying to reduce wt and eat healthily Diabetes well controlled Reported symptoms – Uses a hot water bottle for pain relief (back and stomach) – Increased burping (no bloating) – Stools normal colour, more constipation than anything (normal for him) On Paracetamol regularly Mr E not keen to use Codeine Diet low in fat, but eating regularly with a good appetite

5. Dietitian recommendations Creon (PERT) prescribed 25,000units 2-3 with meals, 1-2 with snacks/milky drinks – dietitian letter to GP Relax healthy eating and ensure good protein intake Increased soluble fibre and linseeds 2-3 dessert spoons per day for constipation (or laxatives)

6. Outcome of follow up ‘those Creon are good aren’t they?’ ‘the thing that has made a big difference’ PROMs – improved Quality of life Mr E could not be specific on what exactly had improved but ‘he just feels better’ less pain no longer using hot water bottle, bowel action improved and form better, no further burping (above normal!)

7. Who and When to prescribe? Any MDT member Dietitians currently unable to prescribe… Ideally Gastroenterologist/Surgeon/Oncologist prescription on diagnosis anyone with Head of pancreas cancer (80% likely) ASAP – improved nutrition, improved outcome??

9. Aim: To evaluate the impact of PEI therapy on survival in these patients Methods: Retrospective analysis of a prospective database of patients with unresectable PC confirmed by EUS-FNB. Patients with survival <30 days were excluded. All patients were evaluated for palliative chemotherapy. Those diagnosed in the Department of Gastroenterology (group 1) were further evaluated for PEI by 13C-MTG breath test and nutritional status, whereas other patients (group 2) were not. Group 1 patients with PEI were treated by pancreatic enzyme replacement therapy (Creon®, 50,000 Ph.U. lipase/meal and 25,000 Ph.U. lipase/snack). Survival (median and 95%CI) was analyzed by Kaplan-Meier test and Cox regression and compared by Log Rank Test. Results: 66 patients with unresectable PC were included (mean age 69.3 years, range 28-100, 43 male, 50 stage IV), 21 (31,8%) in group 1 and 45 (68.2%) in group 2. Age, tumor stage and PS were similar in both groups. Survival in group 1 (301 days, 95%CI 151-451) was significantly longer than in group 2 (89 days, 95%CI 30- 148) (p=0.002). Palliative chemotherapy and PEI and malnutrition therapy were independent factors associated with longer survival Conclusion: Treatment of PEI and malnutrition has a relevant impact on survival in patients with unresectable PC.

10. Anything else? PPIs? Mr Es symptoms returned April 2015 – ?increase PERT – ?start PPI

11. Why/when is PERT needed? Other groups Loss of Pancreatic tissue Asynchrony of enzyme delivery Changes to pH of gut Loss of neural pancreatic stimulation (changes in gastric fundus function) Abnormal/altered Cholecystokinin release Obstruction of pancreatic anastomosis Remember to look for in any UGI surgery