DOI: 10.1097/MEG.0b013e328335ef64
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Issn Print: 0954-691X
Publication Date: 2010/05/01
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Excerpt
I very much appreciate both contributions in response to our paper on the in-vitro properties of different pancreatin preparations because it is giving me the opportunity to clarify some aspects which may have got too short a comment in our original paper [1].
Relating results from the test tube to real patients will inevitably carry some risk for going from ideal, even idealistic conditions to real life. If it comes to enzyme activity, however, things may become even worse when leaving the test tube behind. There are several excellent contributions investigating the enzyme activity. Of these, the pioneering work of Bengt Borgström must be mentioned. In elegant experiments, he clearly showed that the optimum of enzyme activity is between pH 6 and 8. There is virtually no lipase activity below pH 4 and between 10 and 20% between pH 5 and 6, depending on the presence and activity of colipase [2]. As the y-axis is logarithmic, the activity is dramatically lower outside this pH range. Taking this into account we do not expect relevant patient benefit of an enzyme release close to pH 5 or even lower. Undoubtly it would be advantageous to have lipase activity at pH 6 and below, because of the cited situation in patients with chronic pancreatitis and impaired bicarbonate secretion, however, this desire cannot be scientifically supported. Our statement concerning the stability of the enzymes below pH 5 is misleading. Indeed, we referred to the stability of the pancreatin preparation to withstand gastric pH.
Further, both Piehl and Lederer challenge the importance of particle size arguing that we rely solely on the publication of Meyers [3]. However, three other studies using different detection methods demonstrating the pivotal role of particles 2 mm or less are discussed and cited in our study [4–6]. All these data suggest median particle sizes of 1.7 mm or less to be optimal, which reflects precisely the discussion in our paper and hence is in no disagreement whatsoever with Piehl and Lederer. Demonstrating no difference in the emptying of larger particles with differently heavy meals, as mentioned by Lederer, is self-consistent. However, the cited studies are irrelevant as they did not deal with pancreatin preparations at all but cardiac drugs; because of the long time frame one would wonder if the enzyme activity of any pancreatin would be sufficiently preserved [7]. Undoubtly, too small of a size in enzyme preparations would also be disadvantageous, because of gastrocibal asynchronisia with particles less than 1 mm leaving the stomach ahead of the food. This is not questioned by our study since we did not discuss it.
In ordinary pancreatic exocrine insufficiency, indeed, gastric emptying as well as the intestinal functions are initially not impaired. Many patients in need for pancreatic enzymes may suffer from diabetes mellitus or underwent surgical procedures. Those patients represent a therapeutic challenge which is addressed in-depth elsewhere [8] but was not the subject of our study.
