PERTurbations in the pancreas

Treatment of pancreatic exocrine insufficiency (PEI) sounds easy because pancreatic enzyme replacement therapy (PERT) is safe and has virtually no side effects. There are recent guidelines turning the scientific evidence in concrete therapeutic recommendations [1, 2]. The paper by Kumar et al. in this issue of the Journal of Internal Medicine takes a bird eye's view screening a database of 74 million individuals, matching 20,700 chronic pancreatitis and pancreatic cancer patients with the prescription of pancreatic enzymes—which only 27% of them received [3]. Given the incidence of PEI in chronic pancreatitis and pancreatic cancer, at least 50% will be in need for PERT [4]. These data corroborate smaller but more detailed studies from the United States where PERT was given correctly in 30% [5] and Europe with 60%–80% of the patients with chronic pancreatitis receiving proper PERT [6, 7]. This short paper conveys an important message as it puts a flashlight on a deficiency of our own doing: treating our patients right. As solid as these data are, from this height, some shortcomings are noteworthy: although chronic pancreatitis and pancreatic cancer are the two major diseases with PEI and hence prime indications for PERT, other conditions exist such as diabetes mellitus [8] and the elderly [9]. Admittedly, the frequency of correctly identifying and treating PEI will be even lower here. One also might have looked back in this national database from the enzyme prescriptions to the linked diagnoses to learn about other indications for PERT. Finally, the incidence of chronic pancreatitis and pancreatic cancer based on the reported ICD codes seems rather low. As PEI in chronic pancreatitis and pancreatic cancer is on the rise [10], the study by Kumar should be taken as a call for action for all those diagnosed with a pancreatic disease to search for PEI and then treat it according to the guidelines [1, 2]. For those not seeing these patients on a daily basis, the United European Gastroenterology (UEG) has provided an app free of charge containing more than 30 gastroenterology-related guidelines, including the one on PEI and PERT (see https://ueg.eu/quality-of-care/search-guidelines/gi-guidelines-app). The author declares no conflict of interest.