Pancreaze (Pancrelipase) for Patients With Pancreatic Adenocarcinoma With Cachexia and Exocrine Pancreatic Insufficiency

• Pancrelipase (Drug): Pancrelipase delayed-release capsules

Primary outcomes

• Feasibility of Completing Pancreatic Enzyme Replacement Therapy During the First 8 Weeks of the Study: Daily Compliance Diary [8 weeks]: Adherence to therapy of at least 50% of the needed total lipase units, recorded using a daily compliance diary.

Secondary outcomes

• Mean Change in Weight From Baseline Through the End-of-study Visit [6 months]
• Mean Change in Calories Consumed From Baseline Through the End-of-study Visit [6 months]: As measured by Automated Self-Administered 24-Hour (ASA24) Dietary Assessment Tool. The ASA24 is a system to collect 24-hour food recalls and provide complete nutrient analysis of the foods and beverages consumed during the collection timeframe. The tool is used in this study to measure total calories consumed.
• Mean Change in Stool Frequency From Baseline Through Cycle 3 Day 1 [8 weeks]: As measured by patient reported number of bowel movements in the past 24 hours. In this study, higher numbers represent more severe symptoms; a reduction in number of bowel movements in the past 24 hours represents improvement in symptoms.
• Mean Change in Stool Consistency From Baseline Through Cycle 3 Day 1 [8 weeks]: As measured by patient reported stool consistency using the Bristol Stool Chart.The Bristol Stool Chart is a diagnostic scale to classify stool into 7 different groups, ranging from Type 1-7 (indicating solid to liquid consistency or time spent longest in the bowel to least time in the bowel). A normal stool should be either Type 3 or Type 4 (middle of the scale). Worsening of stool consistency is denoted by classifications located closer to the extreme ends of the scale (Type 1 or Type 7).
• Mean Change in Serum Levels of Fat-soluble Vitamins From Baseline - Vitamin A [6 months]
• Mean Change in Serum Levels of Fat-soluble Vitamins From Baseline - Vitamin D [6 months]
• Mean Change in Serum Levels of Fat-soluble Vitamins From Baseline - Vitamin E [6 months]
• Mean Change in Serum Levels of Fat-soluble Vitamins From Baseline - Vitamin K [6 months]
• Mean Change in Serum Levels of Fat-soluble Vitamins From Baseline - Vitamin K PT [6 months]
• Change in Microbiome From Baseline [8 weeks]: Microbiome analysis of stool samples
• Mean Change in Daily Activity (Steps Taken) From Baseline [6 months]: As measured by continuous daily wearable activity monitor
• Mean Change in Daily Activity (Stairs Climbed) From Baseline [6 months]: As measured by continuous daily wearable activity monitor
• Mean Change in Sleep Disturbance From Baseline [6 months]: As measured by continuous daily wearable activity monitor
• Mean Change in Duration of Sleep Disturbances From Baseline [6 months]: As measured by continuous daily wearable activity monitor. An absolute change in the percentage of time during nighttime sleep in which participants experienced sleep disturbance is being reported.An absolute change in percent is understood to be calculated as the value at the later time point minus the value at the earlier time point (e.g., value at 6 months minus value at baseline).
• Mean Change in Average Heart Rate From Baseline [6 months]: As measured by continuous daily wearable activity monitor
• Mean Change in Peak Heart Rate From Baseline [6 months]: As measured by continuous daily wearable activity monitor
• Mean Change in Daily Active Minutes From Baseline [6 months]: As measured by continuous daily wearable activity monitor

Sex: All, ages: 18 Years to any

Inclusion Criteria:

1. Borderline resectable, locally advanced, and advanced pancreatic cancer patients (can include new or recurrent diagnosis) referred to SOCCI-CSMC (Samuel Oschin Cancer Center - Cedars Sinai Medical Center)
2. Age ≥ 18 years.
3. ECOG performance status 0-1 or Karnofsky PS >60%
4. Clinical diagnosis of exocrine pancreatic insufficiency
5. Cachexia defined as at least 5% weight loss in the presence of chronic illness, within any 6-month period prior to screening OR as documented by the medical physician based on standard diagnosis of cachexia
6. Life expectancy of greater than 3 months, in the opinion of the investigator.
7. Patients must have normal organ and marrow function as defined below:

   * Absolute Neutrophil Count (ANC) ≥ 500/mcL
   * Platelets ≥ 50,000/mcL
   * Total bilirubin ≤ 5X upper limit of normal (ULN)
   * AST(SGOT)/ALT(SGPT) ≤ 5 X ULN
   * Creatinine OR creatinine clearance ≤ 3 times the upper limit of normal OR ≥ 30 mL/min/1.73 m² for patients with creatinine levels above normal.
   * Note: Patients with biliary stents are eligible provided that all other inclusion criteria are met.
8. Woman of child-bearing potential (WOCBP) and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) from the time of signing the informed consent form, for the duration of study participation, and for at least 30 days after discontinuing from study treatment.
9. Ability to understand and the willingness to sign a written informed consent document

Exclusion Criteria:

1. Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements.
2. Women who are pregnant or are breastfeeding
3. Dementia or altered mental status that would prohibit the understanding or rendering of informed consent
4. Unable to swallow intact capsules
5. Fibrosing colonopathy: Patients with history of fibrosing colonopathy have been reported to experience advancement to colonic strictures with doses of lipase>6000 units/kg/meal over prolonged periods of time.
6. History of chronic illness associated with malabsorption or nutrient deficiency including but not limited to chronic pancreatitis, cystic fibrosis, celiac disease, Crohn's disease, pernicious anemia and/or prior intestinal resection.
7. Coexistent other primary malignancy
8. Pregnancy, breastfeeding, or of childbearing potential and not willing to use methods of birth control during the study
9. Active drug abuse or intoxication with any substance including alcohol (blood alcohol content >0.08%, legal driving limit)
10. Known allergy to any of the active ingredients in pancreatic enzyme supplementation
11. Concurrent use of pancreatic enzyme supplementation or over the counter supplements which contain lipase, protease, and amylase as active ingredients

Participant flow

Outcome results

• Feasibility of Completing Pancreatic Enzyme Replacement Therapy During the First 8 Weeks of the Study: Daily Compliance Diary (Primary), Count of participants, Participants: Standard of Care Treatment With Pancreaze (Pancrelipase) 29
• Mean Change in Weight From Baseline Through the End-of-study Visit (Secondary), Mean, lbs: Standard of Care Treatment With Pancreaze (Pancrelipase) -2.1931 +/- 6.163831
• Mean Change in Calories Consumed From Baseline Through the End-of-study Visit (Secondary), Mean, calories: Standard of Care Treatment With Pancreaze (Pancrelipase) -169.2075 +/- 969.6394
• Mean Change in Stool Frequency From Baseline Through Cycle 3 Day 1 (Secondary), Mean, bowel movements/day: Standard of Care Treatment With Pancreaze (Pancrelipase) -0.96296 +/- 2.457038
• Mean Change in Stool Consistency From Baseline Through Cycle 3 Day 1 (Secondary), Mean, units on Bristol Stool Form Scale: Standard of Care Treatment With Pancreaze (Pancrelipase) -0.407407 +/- 1.906654
• Mean Change in Serum Levels of Fat-soluble Vitamins From Baseline - Vitamin A (Secondary), Mean, mcg/dL: Standard of Care Treatment With Pancreaze (Pancrelipase) -0.5 +/- 14.70231
• Mean Change in Serum Levels of Fat-soluble Vitamins From Baseline - Vitamin D (Secondary), Mean, ng/mL: Standard of Care Treatment With Pancreaze (Pancrelipase) -5.37619 +/- 12.44841
• Mean Change in Serum Levels of Fat-soluble Vitamins From Baseline - Vitamin E (Secondary), Mean, mg/L: Standard of Care Treatment With Pancreaze (Pancrelipase) 0.495 +/- 3.988863
• Mean Change in Serum Levels of Fat-soluble Vitamins From Baseline - Vitamin K (Secondary), Mean, pg/mL: Standard of Care Treatment With Pancreaze (Pancrelipase) -27.47059 +/- 676.6716
• Mean Change in Serum Levels of Fat-soluble Vitamins From Baseline - Vitamin K PT (Secondary), Mean, pg/mL: Standard of Care Treatment With Pancreaze (Pancrelipase) -0.2190476 +/- 2.82889
• Change in Microbiome From Baseline (Secondary)
• Mean Change in Daily Activity (Steps Taken) From Baseline (Secondary), Mean, steps/day: Standard of Care Treatment With Pancreaze (Pancrelipase) -0.3 +/- 3.8
• Mean Change in Daily Activity (Stairs Climbed) From Baseline (Secondary), Mean, stair steps/day: Standard of Care Treatment With Pancreaze (Pancrelipase) 1332.6 +/- 539.4
• Mean Change in Sleep Disturbance From Baseline (Secondary), Mean, hours/night: Standard of Care Treatment With Pancreaze (Pancrelipase) 0.5 +/- 0.83
• Mean Change in Duration of Sleep Disturbances From Baseline (Secondary), Mean, % of nighttime sleep: Standard of Care Treatment With Pancreaze (Pancrelipase) 4.43 +/- 1.3
• Mean Change in Average Heart Rate From Baseline (Secondary), Mean, beats per minute: Standard of Care Treatment With Pancreaze (Pancrelipase) 0.8 +/- 2.6
• Mean Change in Peak Heart Rate From Baseline (Secondary), Mean, BPM: Standard of Care Treatment With Pancreaze (Pancrelipase) 9.6 +/- 5.4
• Mean Change in Daily Active Minutes From Baseline (Secondary), Mean, minutes/day: Standard of Care Treatment With Pancreaze (Pancrelipase) 3.0 +/- 6.7

Adverse events

Time frame: 6 months

Serious adverse events by term

Other adverse events by term

• Study Protocol and Statistical Analysis Plan (PDF, 2023-05-18)
• Informed Consent Form (PDF, 2023-05-25)

• Andrew Hendifar, MD, MPH, Principal investigator, Cedars-Sinai Medical Center