Starting Treatment: Educating Patients and Initiating PERT for EPI

Once a diagnosis—or high clinical suspicion—is established, the panel turns to what comes next: patient education, treatment initiation, and supportive care coordination. Jennifer Geremia leads with the importance of educating patients that EPI is a long-term condition requiring long-term therapy. Without this foundational understanding, patients often stop therapy or take it inconsistently—since timing relative to meals is critical, any deviation compromises efficacy.

Sarah Enslin emphasizes setting realistic expectations from the start: patients should know what to anticipate in terms of timeframe for improvement and understand that dose adjustments are routine and do not indicate disease progression. She introduces the weight-based dosing framework and advises that providers build in a check-in at one to two weeks to assess and adjust. Capsules must always be taken with meals—not opened and sprinkled directly—though mixing with applesauce is acceptable as long as consumption is immediate.

The panel discusses ancillary support services with enthusiasm. Smoking and alcohol cessation are flagged as mandatory conversations, now embedded in their electronic health record workflows. Nutrition consults are described as transformative—a dietitian's ability to help patients maintain a pancreas-friendly diet within the constraints of their cultural preferences, financial resources, and lifestyle is something no provider can fully replicate. The shortage of dietitians in gastroenterology practice is explicitly called out as an unmet need.

Checking fat-soluble vitamin levels (A, D, E, K) at diagnosis and supplementing as needed is highlighted as an early, high-priority step. The panel also advocates for psychological support—particularly cognitive behavioral therapy—for patients who develop food fear or social anxiety. Palliative care is increasingly being invoked earlier in the care pathway, particularly for severely debilitated patients with chronic pancreatitis, to address pain and nutritional rehabilitation and break the cycle of repeated emergency department visits.

In the next episode, "Optimizing PERT: Dosing, Adjustments, and Managing Non-Responders in EPI," the panel provides practical guidance on fine-tuning PERT therapy—covering weight-based dosing, the role of PPIs, uric acid considerations, and strategies for patients who fail to respond to initial treatment.