Pancreatic enzyme products: digesting the changes.

OBJECTIVE: To review the pharmacology, dosage regimens, efficacy, and safety of currently marketed pancreatic enzyme products (PEPs). DATA SOURCES: Studies were identified by PubMed (1966-January 2011), clinicaltrials.gov, fda.gov, and International Pharmaceutical Abstracts. Search terms included pancreatic enzyme, lipase, Creon, Zenpep, Pancreaze, and exocrine pancreatic insufficiency (EPI). STUDY SELECTION AND DATA EXTRACTION: All human studies evaluating the efficacy of currently approved or potential PEPs were reviewed. DATA SYNTHESIS: PEPs are composed of porcine lipase, amylase, and protease and are used in patients with EPI secondary to cystic fibrosis, chronic pancreatitis, and pancreatectomy. In 1938, PEPs were exempted from the Food, Drug, and Cosmetic Act of 1938 and never underwent a formal Food and Drug Administration (FDA) review process. In response to reports of treatment failures during product interchange, the FDA conducted a review of available PEP products. This review found a large variability of response between the unapproved PEP products, which resulted in the FDA requiring approval of all PEP products by April 2010. The 3 delayed-release, enteric-coated PEPs currently approved by the FDA (Creon, Zenpep, and Pancreaze) have demonstrated efficacy and safety in EPI secondary to cystic fibrosis. Creon has also demonstrated safety and efficacy in EPI secondary to chronic pancreatitis and pancreatectomy. Cost difference between the 3 products is minimal. Treatment-related adverse events in clinical studies for all PEPs were less than or similar to those with placebo. CONCLUSIONS: At this time, Creon is an appropriate first-line agent, as it has been approved for chronic pancreatitis, pancreatectomy, and cystic fibrosis.

Prevention of postoperative nausea and vomiting.

OBJECTIVE: To review the literature on the prevention of postoperative nausea and vomiting (PONV) in adults. DATA SOURCES: Literature retrieval was accessed through MEDLINE (1966-December 2006) using the terms postoperative nausea and vomiting, prevention and treatment. Article references were hand-searched for additional relevant articles and abstracts. STUDY SELECTION AND DATA EXTRACTION: All studies published in English were evaluated. Those dealing with prevention and treatment of PONV in adults were included in the review. DATA SYNTHESIS: Evidence suggests that providing prophylactic antiemetic medications in high-risk surgical patients is warranted. 5-HT3 receptor antagonists are widely used, with no one agent being clearly superior. However, studies have shown other types of agents to be more cost-effective. CONCLUSIONS: The first step in the prevention of PONV is assessment and reduction of risk factors. Although nonpharmacologic therapies may play a role in the treatment of PONV, the mainstay of therapy for PONV is pharmacologic modalities. Patients at moderate to high risk for PONV need prophylactic antiemetic therapy. High-risk patients may require combination therapy with 2 or 3 agents from different antiemetic classes. Rescue antiemetic therapy is needed by patients who actually develop PONV. The agents of choice in such cases should be from antiemetic classes different from those used for prophylaxis of PONV.