Inflammation of the Pancreas: Drug Therapy

Acute pancreatitis

Therapeutic target

  • Avoidance of complications
  • Adequate pain management
  • Healing of the disease

Therapy recommendations

  • Admit patients to a hospital as early as possible to avoid complications.
    • Risk stratification using the Acute Physiology And Chronic Health Evaluation Score (APACHE II).
  • In most patients (85 to 90%), acute pancreatitis is a self-limiting disease (“ending without external influences”) and resolves within three to seven days after initiation of therapy. There is no causal (etiologic) therapy; symptoms are treated primarily:
    • Analgesia (pain relief): pain therapy should follow the WHO staging scheme:

      In the initial phase, a parenteral application (“bypassing the intestine”) is required.In severe pain, the installation of a peridural catheter (PDA) should be considered. Note: freedom from pain facilitates mobilization, improves respiratory function and reduces nausea → prevention of thrombosis (vascular disease in which a blood clot (thrombus) forms in a vein) and pneumonia (pneumonia).

    • Nutrition
      • Oral food and fluid abstinence
      • Placement of a feeding tube for recurrent vomiting and/or subileus/ileus (intestinal obstruction).
      • Fluid therapy/volume therapy: compensation of fluid and electrolyte losses (fluid substitution with Ringer’s lactate as buffered whole electrolyte solution (VEL)): Rapid and adequate fluid intake are especially important. Volume therapy should be individualized:
        • Generous (500-1,500 ml) intravenous fluid administration within the first hours after hospital admission.
        • Up to 8 l/24 h in the first three days under CVD control/central venous pressure (8-12 cm).
        • Notice. In acute necrotizing pancreatitis, fluid loss may be up to 10 l/d (fluid sequestration)
        • Infusion rate: 5-10 ml/kgKG until clinical targets are reached: Heart rate < 120/min, mean arterial pressure (MAP) 65-85 mmHg, urine output > 0.5-1 ml/kgKG and hour, hematocrit (volume fraction of cellular components in total blood volume) 35-44%.
      • Nutritional therapy: parenteral nutrition (“bypassing the digestive tract“) to relieve the pancreas: early enteral nutrition (via a nasojejunal tube/nasal tube that extends into the small intestine in severe cases) helps prevent infection and sepsis (blood poisoning).
    • Anti-inflammatory therapy (anti-inflammatory therapy): anti-inflammatory drugs (anti-inflammatory drugs), antiproteases, antioxidants and antibodies have not been successful in studies.
    • Antibiotic therapy (antibiosis) for: Cholangitis (bile duct inflammation), abscesses (encapsulated pus accumulation), necrosis (death of tissue)/pseudocysts (cyst-like structure), sepsis; prophylactic in severe necrotizing pancreatitis; duration of therapy at least 7-10 days.
    • Stress ulcer prophylaxis with proton pump inhibitors (proton pump inhibitors, PPI; acid blockers) in severe course.
    • Thromboembolism prophylaxis (preventive measures to prevent thrombosis/blood clots in a blood vessel).
    • Hypertriglyceridemia-induced acute pancreatitis: plasma separation or lipid apheresis (therapeutic blood purification procedure).
  • Intensive care monitoring/care for:
    • Suspected necrotizing pancreatitis or any patient with severe pancreatitis according to the Atlanta classification
    • Fulfillment of SIRS criteria, sequential organ failure assessment (SOFA), or acute physiology and chronic health evaluation score (APACHE II, e.g., > 8)
    • Evaluation of acute pancreatitis as severe: see modified Glasgow criteria below (see pancreatitis/sequelae/prognostic factors below).
    • Aanwezigheid van specifieke patiëntkenmerken volgens de richtlijnen van het American College of Gastroenterology (ACG) die een verhoogd risico vormen voor een ernstig verloop van acute pancreatitis (zie hieronder Pancreatitis/Subsequent Conditions/Prognostic Factors).
  • Zie ook onder “Verdere therapie”.

Chronische pancreatitis

Therapeutisch doel

  • Adequate pijnbestrijding
  • Vermijding van complicaties

Therapie-aanbevelingen

  • De therapie van de acute episode van chronische pancreatitis verschilt niet van die van acute pancreatitis (zie boven)Cave! Door chronische pijn, die vaak resistent is tegen therapie, ontwikkelen veel patiënten analgetica-misbruik (pijnstiller-misbruik) of mogelijk opiaat-afhankelijkheid.
  • Analgesie (pijnstilling): pijntherapie volgens het WHO-stappenschema (zie boven ); zo nodig ook CT-geleide blokkade van de plexus coeliacus.
  • Exocriene pancreasinsufficiëntie (EPI; ziekte van de pancreas die gepaard gaat met onvoldoende productie van spijsverteringsenzymen):
    • Substitutietherapie, d.w.z. enzymvervanging (zie onder Pancreatic Insufficiency/Pharmacotherapy for Exocrine Pancreatic Insufficiency):
      • Doel is om ~30.000 I.U. lipase per maaltijd in de twaalfvingerige darm te brengen; gemakkelijk toegediend:
        • Aan het begin van elke hoofdmaaltijd: dosis van 25.000 I.U.
        • Bij het begin van elk tussendoortje: dosis van 12.500 I.U.

        Het succes van de substitutietherapie wordt aangegeven door klinische parameters (steatorroe, gewichtstoename).

  • Endocriene insufficiëntie van de pancreas (de pancreas produceert minder of geen insuline meer; ongeveer 80% van de patiënten): zie hieronder Therapie van diabetes mellitusNoot: de therapie van diabetes mellitus type 3c omvat ook maatregelen tot wijziging van de levensstijl.
    • Tegelijkertijd ondervoeding → therapie met insuline (werkt anabool).
    • In geval van lichte hyperglykemie → therapie met metformine (voor zover er geen contra-indicaties zijn)
  • Profylactische antibioticatherapie is niet aangewezen
  • Zie ook onder “Verdere therapie”.