Transcript Drug use changes after Whipple

Drug use changes after Whipple
pancreaticduodenectomy
KATE VELTMAN
What is a Whipple procedure?
 Removal of the head of the pancreas, part of the bile
duct, gallbladder, and duodenum
 Part of the stomach may or may not be removed
 Performed for:
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Cancers in the pancreas, duodenum, bile duct, or ampulla
Chronic pancreatitis
Benign tumors of the head of the pancreas
http://www.riversideonline.com/health_reference/Cancer/DS00357.cfm
Pancreatogenic diabetes
Parameter
Type I
Juvenile-onset
IDDM
Type II
NIDDM
Type III
Pancreatogenic
Ketoacidosis
Common
Rare
Rare
Hyperglycemia
Severe
Usually mild
Mild
Hypoglycemia
Common
Rare
Common
Peripheral
insulin
sensitivity
Normal or
increased
Decreased
Increased
Hepatic insulin
sensitivity
Normal
Normal or
increased
Decreased
Insulin levels
Low
High
Low
Glucagon levels
Normal or high
Normal or high
Low
Diabetic goals and management
 A1C ≤ 7%
 Fasting plasma glucose 70 – 130 mg/dL
 Begin insulin therapy with A1C ≥ 8.5%
 Begin treatment with pancreatic enzymes
 There is no clear-cut guideline for treatment
Class
Medications
Mechanism of action
Sulfonylureas
Glyburide;
glimepiride;
glipizide
Stimulates insulin secretion in beta
cells
Biguanides
Metformin
Decreases insulin resistance in the
liver
Glucagon-like peptide
agonists
Byetta; Victoza
Binds GLP-1 receptors to enhance
insulin secretion and decrease
glucagon release
Thiazolidinediones
Pioglitazone;
rosiglitazone
Bind PPAR on the fat and vascular
cells to reduce insulin resistance in
the periphery
α-Glucosidase inhibitors
Acarbose;
miglitol
Decrease post-prandial highs by
delaying absorption of complex
carbohydrates
DPP-4 inhibitors
Sitagliptin;
saxagliptin
Reduce post-prandial elevated
glucagon and improve insulin
response
Class
Medications
Mechanism of action
Sulfonylureas
Glyburide;
glimepiride;
glipizide
Stimulates insulin secretion
in beta cells
Biguanides
Metformin
Decreases insulin resistance
in the liver
Glucagon-like peptide
agonists
Byetta; Victoza
Binds GLP-1 receptors to enhance
insulin secretion and decrease
glucagon release
Thiazolidinediones
Pioglitazone;
rosiglitazone
Bind PPAR on the fat and vascular
cells to reduce insulin resistance in
the periphery
α-Glucosidase inhibitors
Acarbose;
miglitol
Decrease post-prandial highs by
delaying absorption of complex
carbohydrates
DPP-4 inhibitors
Sitagliptin;
saxagliptin
Reduce post-prandial elevated
glucagon and improve insulin
response
Steatorrhea
 The presence of fat in stool
 Due to a lack of bile acids and decrease of pancreatic
enzymes
 Impacts absorption of fats, which therefore impacts
absorption of Vitamins A, D, E and K
Treatment of steatorrhea
 Diet changes
 Start with 50 gm fats per day and increase
 Avoid exceeding 100 gm fat per day
 Small and frequent meals
 Drug therapy
 Pancreatic enzymes
Includes lipase, protease and amylase
 Begin at 500 U lipase/kg/meal and increase if symptoms persist
 Max dose: 10,000 U lipase/kg/day OR 2,500 U lipase/kg/meal OR
4,000 U lipase/gm fat/day
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Possibly H2 blocker or PPI
 NOTE: Can affect diabetic control!
Sources
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1. Braga M, Cristallo M, De Franchis R, et al. Correction of malnutrition and maldigestion with enzyme
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2. Cui YF, Andersen DK. Pancreatogenic diabetes: Special considerations for
management. Pancreatology. 2011;11(3):279-294.
3. Knop FK, Vilsbøll T, Larsen S, et al. Increased postprandial responses of GLP-1 and GIP in patients
with chronic pancreatitis and steatorrhea following pancreatic enzyme substitution. American Journal
of Physiology-Endocrinology And Metabolism. 2007;292(1):E324-E330.
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5. USC Department of Surgery. Whipple
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20resection/whipple%20operation.html. Accessed November/03, 2012.
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http://www.accessmedicine.com.proxy.lib.umich.edu/content.aspx?aID=5217299. Accessed
November 4, 2012.
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2001;3(2):101-108.