Lowering doses of pancreatic enzyme supplementation in patients with cystic fibrosis

Introduction: In 1992, fibrosing colonopathy was noted in patients with cystic fibrosis (CF). High doses of pancreatic enzyme supplements were felt to be an etiologic factor. We developed an algorithm for decreasing pancreatic enzyme doses of patients who were receiving doses higher than those recommended by the CF foundation. Aims: To decrease pancreatic enzyme doses in patients with CF receiving high doses by 1) identifying the factors responsible for the presumed need for high doses, 2) identifying the successful interventions associated with the use of lower doses. Methods: We surveyed all patient charts at our CF center and determined their dose of pancreatic enzymes (lipase unitslkg/meal). All patients who were receiving more than 3000 lipase unitslkg/meal were included in the study. Charts were analyzed for reasons for excessive dosing, medications and factors responsible for decreasing enzyme dosing. A computerized program (SPSS 9.0) was used for statistical analysis. Results: Of the 176 patients followed at the CF center, 58 patients (33%) were on high doses of enzymes. Mean age at the time of intervention was 12.6 years z 4.6 SD. Prior to intervention, mean dose of enzyme supplementation was 6372 ::': 3143 SD lipase unitslkg/meal. Following intervention, the mean dose was 3414 ::': 1145 SD lipase unitslkg/meal (p less than 0.001). Dosage of enzyme was changed in 56 patients (97%). Preparation type was changed in 40 patients (69%). Interventions included change in timing of enzyme administration in 21 patients (44%), dietary changes after analysis of diet history in 30 patients (58%): addition of fiber in 6 patients (15.4%), removal of excess juice intake in 1 patient (2.1%). Dose of histamine receptor (H2) blockers were changed in 38 patients (66%); 16 were decreased, 22 increased. A stool softener was added in 17 patients (29%). Conclusions: The identification of the reason for high doses of pancreatic enzymes and the development of a systematic approach for all patients in a CF center allows for the successful intervention and the use of lower and more appropriate pancreatic enzyme replacement therapy.