Pancreatic enzyme replacement therapy for exocrine pancreatic insufficiency-Insights into prescribing practices

Exocrine pancreatic insufficiency (EPI) can affect individuals with a wide range of diseases. Despite the publication of multiple international guidelines, the prescribing practices vary across the globe. The present study was done with an aim to assess how doctors in India evaluate and manage EPI, focusing on usage of pancreatic exocrine replacement therapy (PERT) and barriers to its use.

This was a cross-sectional questionnaire-based survey using Google forms. Doctors practicing gastroenterology were invited using email, social media networks to participate voluntarily. Trainees were excluded to ensure that the responses reflected independent clinical practice. The questionnaire was designed to assess the following domains: evaluation of EPI, use of PERT, response to therapy, strategies for non-response and perceived barriers to therapy.

Total 586 doctors were approached for the questionnaire survey between May 2023 and January 2024. Responses were received from 520 doctors, eight were excluded as they were still in training. Among the doctors most were gastroenterologists, in private practice with a mean age of 42.2 (SD 9.4) years. Fecal elastase-1 appeared to be the most popular test for testing EPI. The most common indication for starting PERT was symptomatic EPI. Approximately 50% of doctors reported prescribing PERT in the setting of AP. The most common indication for PERT in acute pancreatitis was acute necrotizing pancreatitis (ANP). Most doctors prescribed 25,000 lipase units with each major meal and 10,000 units with snacks. Cost of therapy appeared as the biggest limitation for therapy with PERT. A majority (86.1%) of doctors were assessed for response, relying primarily on clinical indicators. Non-response is managed by dose increase and adjunctive therapies.

This large questionnaire-based survey conducted across India suggests that while the management of EPI generally aligns with published international guidelines, there is a pressing need for India-specific recommendations, particularly to address cost-related barriers that impact access to PERT.