A quick review of canine exocrine pancreatic insufficiency - Veterinary Medicine
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A quick review of canine exocrine pancreatic insufficiency
Small bowel diarrhea or loose feces is a hallmark of this condition in dogs, which can now be easily identified with a simple diagnostic test and successfully treated with pancreatic enzyme supplementation.


VETERINARY MEDICINE


SUBCLINICAL EPI

As previously discussed, clinical EPI does not result until 90% of the secretory capacity of the exocrine pancreas is lost. Mild decreases in pancreatic function have been detected in clinically normal dogs. This condition has been termed subclinical EPI and may reflect partial pancreatic acinar atrophy. In affected dogs, repeated cTLI results fall between 2.5 and 5 g/L; a single subnormal value is not diagnostic for subclinical EPI.2 In one study, 20 of 35 (57%) of dogs with subnormal results had normal cTLI concentrations when retested.23 Further, the detection of reduced pancreatic function should not be mistaken for progressive disease. The length of the subclinical phase is highly variable, and some dogs never develop clinical EPI.24

Dogs with borderline fasting cTLI results can be further tested by using the TLI stimulation test, in which cTLI is measured before and after pancreatic stimulation.23 Food is usually used for pancreatic stimulation. Endogenous stimulation by intravenous administration of cholecystokinin and secretin has also been effective experimentally in one study.23 A diagnosis of EPI is confirmed if there is no response to stimulation. Dogs with subclinical EPI typically have low fasting cTLI results but normal post-stimulation results.23,24

TREATMENT

Dogs with subclinical EPI do not require treatment. In cases of suspected pancreatic acinar atrophy, the efficacy of immunosuppressive therapy has been studied in hopes of slowing or preventing the development of clinical EPI. Because of the unpredictable progression of subclinical EPI, the use of immunosuppressive medications is not recommended.2,24

Pancreatic enzyme replacement

The mainstay of treatment in dogs with clinical EPI of any cause is pancreatic enzyme replacement. Commercially available preparations are generally derived from porcine pancreas and contain lipase, amylase, and protease for digestion of fats, carbohydrates, and proteins, respectively. The veterinary products come in powdered and uncoated tablet forms (e.g. Viokase-V—Fort Dodge Animal Health; Pancrezyme—Virbac Animal Health), and products approved for use in people are available in all forms and can be used instead if needed. Alternatively, chopped, raw bovine or porcine pancreas can be fed directly.


Table 2 Doses for Pancreatic Enzyme Replacement Therapy
Raw and powdered forms of pancreatic enzyme supplementation have the greatest efficacy, although uncoated tablets may be crushed, making them as efficacious as the powdered form.25 Enteric-coated pancreatic enzyme tablets are not recommended. Theoretically, they protect the enzymes from gastric acidity, but the enteric coating requires pancreatic bicarbonate for removing the coating, making this form inappropriate for dogs with EPI. Supplementing bicarbonate is not recommended, as it increases the production of gastric acid.2,25,26

Pancreatic enzyme supplementation doses are listed in Table 2. Patients that respond poorly to supplementation may improve with dose increases, alternate forms of enzyme replacement, incubation of food with enzymes for 20 to 30 minutes before feeding, or concurrent administration of H2 blockers.2 Theoretically, H2 blockers such as cimetidine or famotidine would reduce gastric acidity and better preserve the enzymes for intestinal use.12 Administration of these drugs could begin during initiation of treatment in all dogs or may be reserved for those with suboptimal response to treatment. Given the cost of treatment, pancreatic enzyme dose reduction can be attempted. Some dogs have been managed adequately with a 50% dose reduction.13


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Source: VETERINARY MEDICINE,
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