APP Perspective: EPI Management

Hello, I’m Sarah Enslin, a physician assistant. Today, we’ll be discussing the management of Exocrine Pancreatic Insufficiency, or EPI—a complex condition that demands a thoughtful, multidisciplinary approach. As Advanced Practice Providers, we are uniquely positioned to play a pivotal role in identifying EPI earlier and improving patient outcomes. EPI is defined as a reduction in pancreatic enzyme activity in the intestinal lumen to a level below that required for normal digestion. Common contributors to EPI include: A loss of functional parenchyma, like we see in chronic pancreatitis, cystic fibrosis, or post-resection. Reduced intestinal stimulation in untreated celiac or Crohn’s disease. Pancreatic duct obstruction (e.g., tumors). Low duodenal pH, which impairs lipase activity. Impaired mixing post-upper GI surgery. Postcibal asynchrony—misalignment between gastric emptying and enzyme delivery—common in gastric surgery, short bowel syndrome, Crohn’s disease, and diabetes. Intraluminal inactivation of enzymes, seen in Zollinger-Ellison syndrome. EPI is prevalent across multiple conditions: Up to 90% of patients with cystic fibrosis or chronic pancreatitis. Over 50% of patients with pancreatic cancer. 27–35% of those with acute pancreatitis. 39% with type 1 diabetes, and 22–28% with type 2 diabetes. Up to 80% of those with undiagnosed or untreated. Even then, nonspecific symptoms like bloating, diarrhea, and weight loss make the diagnosis challenging. The hallmark symptom of EPI, steatorrhea, typically occurs after more than 90% of enzyme function is lost. Furthermore, 34% of gastroenterologists who participated in the EPI Uncovered Survey admitted EPI isn’t top of mind when evaluating patients with these GI symptoms. Let’s take a closer look at the EPI journey. Many patients already face significant underlying health conditions—chronic pancreatitis, cystic fibrosis, inflammatory bowel disease, pancreatic cancer, or diabetes. EPI symptoms can mimic other GI disorders such as irritable bowel syndrome, small intestinal bacterial overgrowth, or celiac disease, which adds to diagnostic complexity. Common symptoms of EPI include: Bloating and gas, Abdominal pain, Diarrhea, Unexplained weight loss. One study found that patients wait nearly 4 years before seeking care.11 Once they do, 1 in 4 is misdiagnosed with another condition first. Standard of care treatment is Pancreatic Enzyme Replacement Therapy (PERT)—porcine-derived lipases, proteases, and amylases. Yet: 70% or more of patients are not prescribed PERT—or not at an appropriate dose, 80% of patients seek information about EPI online due to a lack of guidance, Many patients are confused about dosing and often feel underdosed, Up to 20% of patients skip or reduce dosing themselves, It may take a year or more to find the optimal dose. There are also challenges with adherence. Around 70% of patients stop PERT within a year due to unresolved symptoms, lack of education, pill burden, or inadequate follow-up. So, what can we do? First, be proactive. While 34% of gastroenterologists may overlook EPI, APPs can help close that gap. Also, collaborate. Work with dietitians, gastroenterologists, and primary care to provide comprehensive, coordinated care. Untreated EPI significantly affects patients’ quality of life, leading to: Unintentional weight loss, Fatigue, Difficulty concentrating, Sarcopenia, Metabolic bone loss. Effective management hinges on appropriate PERT use, but over 70% of patients believe they’re not taking enough enzymes. This highlights the critical need for clear communication, ongoing patient education, and regular follow-ups to assess symptoms and adjust dosing as needed. A healthy pancreas secretes 480,000 to 960,000 units of enzymes per meal. Fat malabsorption (steatorrhea) occurs when lipase output drops to <10% of normal levels. PERT is generally considered safe and well tolerated by most patients. However, there are important safety considerations that should be discussed during initiation and monitored throughout treatment.

One common issue is irritation of the oral mucosa, which can occur if patients chew, crush, or hold the capsules in their mouth. To prevent this, it's essential to counsel patients to swallow PERT capsules whole with an adequate amount of fluid, ideally during meals or snacks. In certain patient populations, additional caution is warranted. Patients with a history of gout, renal impairment, or hyperuricemia should be monitored closely, as PERT can increase serum uric acid levels. Likewise, those with a known allergy to porcine proteins—since PERT is derived from porcine sources—should avoid its use or consult with an allergist prior to starting therapy.A rare but serious effect, fibrosing colonopathy, has been reported primarily in patients with cystic fibrosis receiving high doses of PERT. This condition is characterized by strictures in the colon and may be associated with prolonged use of high-dose enzymes. As such, it's important to adhere to recommended dosing guidelines and adjust only as clinically necessary. Follow up is critical yet 70% of patients receive no follow up after starting PERT. As APPs, we can schedule routine check ins, provide practical, on-going education, and improve patient adherence and confidence. To optimize outcomes, we must: Set clear goals and expectations. Educate patients on: Proper PERT timing—as timing affects digestive efficiency, Consistent dosing—adherence is key to success, Patients should be aware that the need for PERT increases with consumption of fat – including fat-containing beverages, It is helpful to follow up within one week of starting PERT to reassess symptoms and adjust dosing if needed. Your role is pivotal in transforming the patient experience. By delivering comprehensive, Let’s continue to collaborate, learn from one another, and inspire patient-centered care in the world of EPI management. Thank you for your dedication and commitment.