CONDITIONS & DISORDERS
DISEASES OF THE PANCREAS: NICE GUIDANCE SUMMARISED Throughout 2018, NICE updated their guidance on managing patients with diseases of the pancreas, including pancreatitis and pancreatic cancer.1,2 This article aims to give an overview of the guidance on dietary recommendations and how HCPs can support this patient group. The pancreatitis NICE guidance NG104 was updated in September 2018.1 This covers advice for both acute and chronic versions of the disease. The guidance initially begins with advising that the patient and their families are provided with written and verbal information on what pancreatitis is, proposed investigations, long-term effects of pancreatitis and the harm caused by smoking or alcohol. Nutrition advice is also mentioned, which includes providing advice on pancreatic enzyme replacement therapy (PERT) if needed. As HCPs, when seeing pancreatitis patients, we often link in with GPs. The NICE guidance emphasises that the information passed onto GPs should include the following where applicable: • detail on how the person should take their PERT (including dose escalation as necessary); • HbA1c testing to be offered at least every six months and bone mineral density assessments every two years. General lifestyle interventions are discussed in the introduction to the guidance and state the following: • Advise people with pancreatitis caused by alcohol to stop drinking alcohol. Advise people with recurrent acute or chronic pancreatitis not alcohol-related that alcohol might exacerbate their pancreatitis. • When discussing smoking cessation with patients, make them aware of the link between smoking and
chronic pancreatitis and advise people with chronic pancreatitis to stop smoking. For support with this, the guidance refers to the NICE guidelines on the diagnosis and management of physical complications of alcohol-use disorders,3 the diagnosis, assessment and management of harmful drinking and alcohol dependence4 and NICE guidance on stop-smoking interventions and services.5 The guidance goes on to discuss specific advice for both acute and chronic pancreatitis, which both have important nutritional aspects.
Rebecca Gasche Registered Dietitian, Countess of Chester Hospital NHS Trust Rebecca has a keen interest and specialises in gastroenterology dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.
Acute pancreatitis is a condition where the pancreas becomes inflamed over a short period of time. The NHS reported 25,000 people were admitted to hospital with acute pancreatitis in the years 20132014.6 Acute pancreatitis can occur at different severities – mild, moderately severe and severe – and usually resolves in 48 hours if it is a mild-moderate form.7 It is usually caused by alcohol consumption or gallstones; however, the NICE guidance emphasises that we should not assume a person’s acute pancreatitis is alcohol-related just because they drink alcohol.1,7 Specifically looking at nutrition support for acute pancreatitis, the guidance advises the following: • Ensure that people with acute pancreatitis are not made ‘nilby-mouth’ and do not have food
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CONDITIONS & DISORDERS
withheld unless there is a clear reason to do so (eg, vomiting). • Offer enteral nutrition to anyone with severe or moderately severe acute pancreatitis. Start within 72 hours of presentation and aim to meet their nutritional requirements as soon as possible. • Offer anyone with severe or moderately severe acute pancreatitis parenteral nutrition only if enteral nutrition has failed or is contraindicated.1 CHRONIC PANCREATITIS
Chronic pancreatitis differs from the acute form as it is an irreversible and long-term inflammation or fibrosis of the pancreas.8 Chronic pancreatitis can lead to endocrine pancreatic insufficiency, resulting from damage to the endocrine tissue of the pancreatic gland (islets of Langerhans), with failure to produce insulin, causing impaired glucose regulation and diabetes mellitus. Pancreatic exocrine insufficiency (PEI) may also occur from damage to the acinar cells, with failure to produce digestive enzymes, causing malabsorption.8 The NICE guidance discusses general nutrition support, as well as highlighting follow up and the condition’s links to diabetes and cancer. It is necessary to identify those who need to be followed up and what tests are required,1 as 46
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people with pancreatitis are at long-term risk of nutritional problems and diabetes and also have an increased risk of pancreatic cancer. The NICE guidance also notes that pancreatitis is a serious and complex condition, which can have a severe effect on quality of life and may result in reduced life expectancy. The guidance states that, in the past, there has been lack of knowledge on how to manage pancreatitis, which has resulted in clinicians avoiding those with the disease and conflicting advice being offered. The guidance, therefore, aims to enable people with pancreatitis to receive appropriate care, thus improving the outcomes of this difficult condition. Similar to the acute pancreatitis advice, the NICE guidance begins with stating that it should not be assumed that a person’s chronic pancreatitis is alcohol-related just because they drink alcohol. Nutrition support • Be aware that all people with chronic pancreatitis are at high risk of malabsorption, malnutrition and a deterioration in their quality of life. • Use protocols agreed with the specialist pancreatic centre to identify when advice from a specialist dietitian is needed, including advice on food, supplements and long-term PERT, and when to start these interventions. • Consider assessment by a dietitian for anyone diagnosed with chronic pancreatitis. TYPE 3C DIABETES
The guidance also discusses the risk of developing diabetes, known as Type 3 diabetes, as a result of pancreatitis. It states that people with chronic pancreatitis have a lifetime risk as high as 80%, and this risk increases with duration of pancreatitis and if calcific pancreatitis is present. It is advised that: • chronic pancreatitis patients are offered monitoring of HbA1c for diabetes at least every six months; • patients with Type 3c diabetes are assessed every six months for potential benefit of insulin therapy.
This guidance signposts to using the appropriate NICE guidance on managing diabetes for support.9,10 FOLLOW-UP
For patients with chronic pancreatitis and PEI it is advised to: • offer people with chronic pancreatitis monitoring by clinical and biochemical assessment, to be agreed with the specialist centre, for PEI and malnutrition at least every 12 months (every six months in under 16s); • adjust the treatment of vitamin and mineral deficiencies accordingly; • offer adults with chronic pancreatitis a bone density assessment every two years. As patients with pancreatitis have an increased risk of developing pancreatic cancer (the lifetime risk is highest, around 40%, in those with hereditary pancreatitis), annual monitoring for pancreatic cancer in people with hereditary pancreatitis should be considered.1 PANCREATIC CANCER
The NICE guidance on pancreatic cancer in adults – diagnosis and management NG85 – was updated in February 2018.2 A main aim of the guidance was to help improve diagnosis and treatment of pancreatic cancer, as the NHS England ‘Five Year Forward View’11 highlighted that there are often delays in access to diagnosis and treatment for patients with pancreatic cancer. The NICE guidance states that many people with pancreatic cancer benefit from dietary counselling to increase their nutritional intake – this may be in the form of food-first methods and the use of ONS. However, the guidance notes that there is variation in the level and type of information given and the routes through which nutrition is provided, also, that there is uncertainty over what are the most effective interventions and routes for providing nutrition. It was also noted that weight loss is common in patients with pancreatic cancer, both in resectable and non-resectable disease. This is likely due to one or a combination
of the following: reduced dietary intake; malabsorption; post-surgical complications affecting nutritional status; cachexia and hyperglycaemia due to impaired glucose tolerance; or undiagnosed diabetes. Weight loss can be severe and debilitating for the patient and contributes towards the development of loss of muscle mass and reduced muscle function, ultimately affecting quality of life. Interestingly, the guidance states that there is considerable variation in the nutritional input received by people with pancreatic cancer in different parts of the country (and in some cases between local hospitals, or GPs and tertiary centres). This has been reported to be an area of confusion for people with pancreatic cancer, their families and some healthcare professionals, meaning that some people continue to experience symptoms that have a negative impact on their quality of life. Good nutritional input can improve quality of life for people with pancreatic cancer and, potentially, improve their ability to undergo oncological treatment and survival. There is a high incidence of PEI in those with pancreatic cancer. It is again noted that there is significant variation in the amount of specialist information people receive on how to take PERT effectively. This results in some patients continuing to experience the symptoms and consequences of poor digestion and not getting the full benefit of this intervention.2 The concluded recommendations in the guidance for nutrition support are as follows: • Offer enteric-coated pancreatin for people with unresectable pancreatic cancer. • Consider enteric-coated pancreatin before and after pancreatic cancer resection. • Do not use fish oils as a nutritional intervention to manage weight loss in people with unresectable pancreatic cancer. • For people who have had pancreatoduodenectomy (also known as a Whipple procedure – where the head of the pancreas, the duodenum, a portion of the stomach, and other nearby tissues are removed) and who have a functioning gut, offer early enteral nutrition (including oral and tube feeding) rather than parenteral nutrition. 2 www.NHDmag.com March 2019 - Issue 142