Nutrition in Clinical Practice

Nutrition in Clinical Practice http://ncp.sagepub.com/

Pancreatic Enzyme Supplementation for Patients Receiving Enteral Feeds Suzie Ferrie, Christie Graham and Matthew Hoyle Nutr Clin Pract 2011 26: 349 originally published online 20 April 2011 DOI: 10.1177/0884533611405537 The online version of this article can be found at: http://ncp.sagepub.com/content/26/3/349

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Techniques and Procedures

Pancreatic Enzyme Supplementation for Patients Receiving Enteral Feeds

Nutrition in Clinical Practice Volume 26 Number 3 June 2011 349-351 © 2011 American Society for Parenteral and Enteral Nutrition 10.1177/0884533611405537 http://ncp.sagepub.com hosted at http://online.sagepub.com

Suzie Ferrie, RD, MNutrDiet1; Christie Graham, RD, MNutrDiet2; and Matthew Hoyle, RD, BNutrDiet(Hons)3 Financial disclosure: none declared.

ery into the feeding tube. This technique minimizes tube blockage by preventing the enzyme from clumping in the tube. For jejunally placed tubes, enzyme microspheres can be crushed and activated with sodium bicarbonate before flushing into the tube, or the activated enzyme mixture can be added to enteral feeds. Conclusions: Pancreatic enzyme supplementation can continue while patients receive enteral feeding. Using the described technique can help to avoid tube blockage and maintain optimal enzyme activity. (Nutr Clin Pract. 2011;26:349-351)

Background: Pancreatic enzyme supplementation is an important part of management for a number of gastrointestinal conditions. For patients who are unable to swallow pancreatin capsules or granules, enteral feeding tubes can be used to administer the pancreatic enzyme. This presents challenges given the unique format of the pancreatic enzyme supplements, with common problems including tube blockage and loss of the enzyme’s effect. Methods and Results: A novel technique is described for administration of pancreatic enzyme via feeding tubes. For gastrically placed tubes, this involves opening the pancreatin capsules and suspending the enzyme microspheres in thickened acidic fluid (such as the mildly thickened or “nectar-thick” fruit juice used for dysphagia) for deliv-

Keywords: pancreatin; pancrelipase; exocrine pancreatic insufficiency; enteral nutrition

P

stomach into the duodenum, where the alkaline environment allows the enteric coating to dissolve and the enzymes to be activated. Their activity peaks at 30 minutes after ingestion and tails off during the course of approximately 2 hours.1 An alkaline environment is essential for optimal enzyme activity. The enteric coating of the microspheres will not break down if the pH is below 5.5, and the amount of viable pancreatic lipase (whether from a supplement or endogenously secreted) is reduced as pH decreases, ceasing altogether at a pH below 4. The pancreas normally secretes concentrated bicarbonate to ensure that its enzymes are provided with the right environment, but in pancreatic insufficiency this function is impaired. Gastric acid hypersecretion occurs with many GI disorders, and this can denature the pancreatic enzymes, causing malabsorption. Successful administration of pancreatic enzyme supplementation into enteral feeding tubes takes into account the importance of pH in the action of this product. Without effective enzyme replacement, patients with pancreatic insufficiency can suffer debilitating malabsorption leading to malnutrition. Enteral feeding presents a challenge to the administration of pancreatic enzyme supplementation, and the removal of non-enterically coated products from the market has created the need for a new administration technique.

ancreatic enzyme supplementation is a valuable part of treatment for a number of gastrointestinal (GI) conditions, including pancreatic insufficiency, cystic fibrosis, altered gut anatomy post resection, some cases of short bowel syndrome, and celiac disease. Combining pancreatic enzyme supplementation with enteral feeding can present challenges, however, given the unique format of the pancreatic enzyme supplement. Pancreatic enzyme capsules consist of enteric “microspheres” of enzyme, sealed in a gelatin capsule. When taken by mouth, the gelatin capsule dissolves in the stomach to release the microspheres. The microspheres’ enteric coating is a pH-sensitive cellulose polymer that is stable in acid but breaks down in an alkaline environment. It therefore protects the microspheres from gastric acid so that they remain intact and disperse among any food that has been consumed at the same time. The whole microspheres and chyme then empty together from the

From the 1Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Sydney, Australia; and 2Children’s Hospital at Westmead, Sydney, Australia. 3Formerly of Townsville Hospital, Townsville, Queensland, Australia. Address correspondence to: Suzie Ferrie, Critical Care Dietitian, RPA Hospital, Missenden Road,Camperdown, 2050 Australia; e-mail: [email protected].

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350 Nutrition in Clinical Practice / Vol. 26, No. 3, June 2011

Methods and Results The methods described here are useful in delivering enzymes to patients with a wide variety of enteral feeding tubes and feeding regimens. To maximize absorption and reduce the risk of tube blockage, it is important to consider the size of the feeding tube, its position in the gut, and the type of feeding regimen (whether continuous, intermittent, or bolus). When pancreatic enzyme supplements are to be given into a duodenally or jejunally placed enteral feeding tube, an activated enzyme solution can be prepared for delivery directly into the feeding tube via syringe, or for mixing into the enteral formula as is the practice in some facilities.2 To make this solution, the microspheres are crushed well to remove the enteric coating and then mixed with an alkaline agent such as sodium bicarbonate to ensure that the enteric coating is fully dissolved and to maintain the ideal alkaline environment for enzyme activity. Some loss of enzyme activity is likely with this method, and dosage should be adjusted to compensate. For each 10,000 international units of lipase, about 800 mg of sodium bicarbonate is used. This is the amount provided by one 10-mL vial of 8.4% sodium bicarbonate solution or by a warm water solution of the contents of 1 capsule of pharmaceutical sodium bicarbonate or about ¼ teaspoon of culinary bicarbonate soda. Alternatively, the uncrushed microspheres can be mixed with the bicarbonate solution and allowed to stand until the enteric coating dissolves spontaneously; this takes about 20 minutes. When pancreatic enzyme supplements are to be given into a gastrically placed enteral feeding tube, the microspheres are ideally left whole so that the enteric coating can protect the enzyme activity from gastric acid. As Figure 1 shows, giving these microspheres as a slurry in water allows them to clump in the feeding tube, causing a blockage that may be impossible to dislodge, whereas the use of a thickened acidic fluid, such as mildly thickened or “nectar”consistency fruit juice (of any type of fruit) has the advantages of maintaining the enteric coating and keeping the microspheres suspended so that they are less likely to clump. Table 1 gives instructions for this technique, which can be used for feeding tubes size 10-Fr and above. Particularly with 10-Fr and 12-Fr tubes, low-dose enzyme capsules (5,000 international units of lipase) or microgranules are recommended for this method because they contain the smallest sized microspheres. Adequate flushing with water, before and after administration, is important to prevent interaction between the acidic juice and the feed formula, which itself can cause clogging of the tube. Medication to suppress gastric acid, such as a protonpump inhibitor, is often recommended in pancreatic insufficiency to optimize the function of both endogenous and supplemented pancreatic enzyme. With sufficient gastric

Figure 1. Effect of thickened fluid in preventing tube blockage. Behavior of enzyme microspheres when given in water (left) versus thickened fluid (right).

Table 1. Instructions for Giving Pancreatic Enzyme Supplements Via a Gastrically Placed Feeding Tube Step 1

Step 2

Step 3

Step 4 Step 5

Step 6

Assemble the equipment: the required dose of pancreatic enzyme capsules or enteric granules, enteral syringe, small clean container, 50-100 mL of mildly thickened (“nectar-thick”) fruit juice, water. Open the pancreatic enzyme capsules (or measure the required dose of granules, if using) and tip the microspheres into the clean container. Add sufficient mildly thickened fruit juice to coat the microspheres well, and stir gently to suspend them evenly through the juice. Pause the tube feeds, and flush the feeding tube with water. Draw up the microspheres with the syringe and deliver into the feeding tube with slow, gentle pressure. Flush the feeding tube with water and resume tube feeds.

acid suppression, it may be possible to give crushed, alkaline-activated enzyme (either as a solution or mixed in enteral feeds) into a gastrically placed tube, as in the jejunal method described above. This may be a preferred method for small-bore feeding tubes (smaller than 10-Fr) that could be blocked by whole microspheres. Neonates and infants requiring tube feeding often have very small-bore feeding tubes. Activated enzyme can be added to their formula or given separately just before each feed. If possible, oral administration of intact enteric enzyme granules should be started as soon as infants are able to take these by mouth, given in a dose that matches the fat content of their tube feeding.


Pancreatic Enzyme Supplementation / Ferrie et al 351

Table 2. Practical Considerations for Pancreatic Enzyme Supplementation Storage

Check expiration date before using the enzymes and ensure that they are always stored appropriately in a cool, dry environment. If ambient temperatures regularly exceed 25°C, store enzyme supplements in the refrigerator. Do not use enzyme capsules with any signs of deterioration, because they may be ineffective. Adherence If enzyme supplementation appears ineffective, check adherence with correct dosing and timing, because errors are common. Dosing There is wide variation in patients’ residual pancreatic function, and many other factors affect enzyme effectiveness, including gut anatomy and food habits, so dosing needs to be individualized according to the patient’s symptoms. The usual recommendation is 5004000 international units of lipase per g of fat3 or 25,000-50,000 international units per meal.4 For enteral feeds, a starting daily dose is 1,000 international units for each g of fat provided by the daily amount of feed. If supplementation appears ineffective and adherence is acceptable, a trial of a higher dose is recommended. Timing Enzyme supplements usually should be taken during a meal or bolus feed or no more than 30 minutes before or after. With enteral feeding, an ideal regimen is to calculate the amount of enzyme needed for the total daily fat intake from the feed formula and divide this into 2-hourly or 3-hourly doses to give at regular intervals during feeding. This can be impractical for supplemental overnight feeding, in which it is more common to limit supplementation to a single dose at the beginning of the feed period, usually a 3-hour amount or 50% of the amount required for the total feed period. An additional dose can be given if the patient awakes spontaneously during the night.5

Discussion Patients with pancreatic insufficiency who also require enteral tube feeding are a nutritionally vulnerable group, and it is essential that their treatments be optimized. Pancreatic enzyme replacement, unlike other medications, is a biologically active agent that works together with ingested macronutrients so that timing and technique are intrinsic to its success. To ensure that this therapy benefits patients, it is imperative that enzymes be delivered in

a simple, rapid, and cost-effective way that maximizes effectiveness. Tampering with the conventional format of the enzyme supplement brings a significant risk of losing some enzyme activity, and the novel method described above is no exception. As an alternative to pancreatic enzyme supplementation, it may be possible to use elemental or semi-elemental formulas, which are low in fat and do not require significant enzyme activity for absorption. However, even with a standard polymeric formula, it may not always be necessary to use enzyme supplementation if enteral tube feeding is given as a 24-hour continuous regimen. This allows a lower feed rate that reduces the risk of overwhelming the digestive capacity of the patient (the activity of the intestinal brush-border enzymes as well as any residual pancreatic function). Standard feeds given continuously will usually provide only 2 or 3 g of fat per hour, reducing the risk of significant malabsorption. Patients with cystic fibrosis might still require some enzyme supplementation in order to break down thick intestinal secretions even when feed is not being given. Pancreatic enzyme supplementation is a complex therapy that enables patients to be nourished via the oral or enteral route when they would otherwise suffer debilitating malabsorption. The strategies discussed here can optimize enzyme effectiveness while avoiding feeding tube blockage, to ensure that despite their condition, tube-fed patients are able to achieve the best possible nutrition status and quality of life.

Acknowledgments We thank Tim Rosser for his assistance with the photography.

References 1. Creon 10,000 [package insert]. Abbott Park, IL: Abbott Laboratories; 2009. 2. Goodin B. Nutrition issues in cystic fibrosis. Pract Gastroenterol. 2005;27:76-94. 3. Anthony H, Collins CE, Davidson G, et al. Pancreatic enzyme replacement therapy in cystic fibrosis: Australian guidelines. J Paediatr Child Health. 1999;35:125-129. 4. Toouli J, Biankin AV, Oliver MR, Pearce CB, Wilson JS, Wray NH. Management of pancreatic exocrine insufficiency: Australasian Pancreatic Club recommendations. Med J Aust. 2010;193:461-467. 5. Stapleton DR, Anthony H, Collins CE, Powell EB, King SJ, Mews CF. Implementing the Australian pancreatic enzyme replacement therapy guidelines for cystic fibrosis. Aust J Nutr Diet. 1999;56:91-96.
