Pancreatic enzyme replacement therapy use in acute pancreatitis - a systematic review of current practice

Up to two-thirds of inpatients with acute pancreatitis (AP) may develop pancreatic exocrine insufficiency (PEI), persisting long-term in one third. The prevalence, indications, and outcomes of pancreatic enzyme replacement therapy (PERT) following AP remain poorly defined, with limited AP-specific guidance in current international guidelines. This systematic review aimed to determine the prevalence of PERT use after AP and its associated outcomes.

Medline, via Ovid and Pubmed, and Embase were searched for studies reporting PERT prescription rates, indications, timing, or outcomes during or after AP. Randomised and non-randomised primary studies in adult populations were eligible. Single-proportion random-effects meta-analyses estimated pooled prescribing rates; evidence certainty was assessed using GRADE.

Twenty-eight studies (14,874 patients) were included. Pooled PERT prescription rates across non-randomised studies, were 17.8% (95% CI 11.4-26.7%) overall, rising to 28.4% (95% CI 15.5-46.0%) in necrotising AP and 42.7% (95% CI 23.8-64.0%) in severe disease, versus 5.0% (95% CI 0.3-45.5%) in mild disease. Outcomes data were inconsistent across biochemical, symptom, and quality-of-life endpoints; heterogeneity precluded meta-analysis of treatment effect. Overall evidence certainty was low.

PERT is infrequently prescribed after AP, and evidence for its benefit remains inconsistent. Well-designed trials stratified by severity, including patient-reported outcomes, are needed.