Management of pain in chronic pancreatitis with emphasis on exogenous pancreatic enzymes

Figure 1 Flow chart demonstrating recommendations for using pancreatic enzyme replacement therapy in a patient with abdominal pain and chronic pancreatitis. ¹Start with non-enteric coated products such as Viokace along with a PPI. The figure suggests approaching the patient with a three-pronged method. First, one should assess the patient’s pain profile and investigate whether the pain is from chronic pancreatitis alone or from other etiologies, i.e., a developing pseudocyst or malignancy. Next, pain control should be attempted first with conservative measures such as lifestyle changes, enzyme supplementation, NSAIDs, and/or gabapentoids before moving to treat with opioids. If opioids are deemed appropriate for pain control, the decision should be consistently reassessed as to avoid dependency and addiction. Second, one should assess the patient for malabsorption, and if present, the patient should be treated with exogenous enzymes as that may improve absorption and pain symptoms. Lastly, the physician should assess the patient’s nutritional status and correct deficiencies, if present. A non-enteric-coated enzyme such as Viokace along with a proton pump inhibitor is recommend for first-line enzymatic treatment. Alternatively, can use combination of non-enteric-coated and enteric-coated formulations. NSAIDs: Nonsteroidal antiinflammatory drugs; PPI: Proton pump inhibitors.