Prevalence of PEI, potential value of PERT and recommendations for less common causes of PEI
| Condition | Prevalence of abnormal FEL-1 | Benefit of pancreatic enzyme supplementation | Recommendation |
| DM83 84 158 162–164 | Type 1: 26%–44% Type 2: 12%–20% | One RCT showing reduction in frequency of hypoglycaemia | Statement 2.4: Patients with DM may have PEI; however, the exact prevalence is not clear. Those with relevant symptoms should be offered PERT and investigated for a pancreatic pathology (grade 2C; 94% agreement) |
| Elderly populations87 165 166 | 11.5%–20% in patients 50–80 years of age 1.5% in patients over 90 years of age | No treatment studies reported | Statement 2.5.1: Ageing populations may have an increased prevalence of PEI and, therefore, should be considered for testing, particularly if presenting with unexplained weight loss or diarrhoea (GPP; 88% agreement) |
| Advanced renal disease167 168 | 10%–48% | No treatment studies reported | Statement 2.5.2: Patients with renal disease and rheumatological conditions may have an increased prevalence of PEI but further studies are needed before routine testing can be recommended (GPP; 95% agreement) |
| Sjögren’s syndrome169 | 4% in secondary Sicca syndrome | No treatment studies reported | |
| Coeliac disease170–172 | Around 30% with diarrhoea | One RCT showing benefit for 3 months after diagnosis. One open-label study showing benefit in those with persistent diarrhoea | Statement 2.5.3: Patients with coeliac disease on a gluten-free diet, but still experiencing diarrhoeal symptoms, should be investigated for PEI and treated with PERT if positive results are obtained. This should be reviewed at least annually as treatment may not need to be long term (grade 1B; 100% agreement) |
| IBS-D103 104 | 6.1%–8.6% | One open-label study showing improved pain, stool frequency and consistency | Statement 2.5.4: PEI should be considered in patients with IBS-D. The role of PERT in this group is not fully understood (grade 2C; 95% agreement). |
| IBD173 174 | 19%–30% | No treatment studies reported | Statement 2.5.5: Patients with inflammatory bowel disease and continued diarrhoeal symptoms should be investigated for PEI (grade 2B; 100% agreement) |
| HIV175 176 | 23%–54% | Open-label studies showing improvement in diarrhoea and fat malabsorption | Statement 2.5.6: Patients with HIV presenting with steatorrhoea, diarrhoea or weight loss should be investigated for PEI and offered PERT if positive results are obtained (grade 2B; 88% agreement) |
| Alcohol-related liver disease177–180 | 7%–20% | No treatment studies reported | Statement 2.5.7: There may be an increased prevalence of PEI in patients with alcohol-related liver disease but the role of PERT in this group has not been examined (GPP; 89% agreement) |
| Somatostatin analogues181 | 24% after a median of 2.9 months of therapy | No treatment studies reported | No statement |
See online supplemental material for more detail.
FEL-1 faecal elastase-1; DM, diabetes mellitus; GPP, good practice point; IBD, inflammatory bowel disease; IBS-D, diarrhoea-predominant irritable bowel syndrome; PEI, pancreatic enzyme insufficiency; PERT, pancreatic enzyme replacement therapy; RCT, randomised controlled trial.