# Pancreatic Cancer - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class DD27 - condition scope only, no dose · NICE NG12: Suspected cancer: recognition and referral (recommendation 1.2.5) - https://www.ncbi.nlm.nih.gov/books/NBK555330/ · No dose - referral pathway, no medicine given in primary care · MSF Essential Drugs 2024 - morphine sustained-release (oral) · Pancreatic Cancer - disease-level clinical article (pancreatic-cancer-full.txt) · NICE NG85 recommendation 1.6.1 for the indication - "Offer enteric-coated pancreatin for people with unresectable pancreatic cancer" - with the dose and the strengths from Creon 25000 Capsules (pancreatin) SmPC sections 2 and 4.2 (eMC product 1168): "Each capsule contains pancreatin PhEur 300 mg equivalent to: Lipase ... 25,000 PhEur units" and "Initially one or two capsules during or immediately after each meal", and Creon 10000 Capsules SmPC section 2 (eMC product 1167) for the smaller strength: "Each capsule contains: Lipase ... 10,000 PhEur units". · NICE NG85: Pancreatic cancer in adults - diagnosis and management (National Institute for Health and Care Excellence, 2018, updated 2019), recommendations 1.6.1 and 1.6.2 - https://www.nice.org.uk/guidance/ng85 - Verified date: 2026-08 ## Verified against - No dose - referral pathway, no medicine given in primary care - Pancreatic Cancer - disease-level clinical article (pancreatic-cancer-full.txt) - MSF Essential Drugs 2024 - morphine sustained-release (oral) - NICE NG85 recommendation 1.6.1 for the indication - "Offer enteric-coated pancreatin for people with unresectable pancreatic cancer" - with the dose and the strengths from Creon 25000 Capsules (pancreatin) SmPC sections 2 and 4.2 (eMC product 1168): "Each capsule contains pancreatin PhEur 300 mg equivalent to: Lipase ... 25,000 PhEur units" and "Initially one or two capsules during or immediately after each meal", and Creon 10000 Capsules SmPC section 2 (eMC product 1167) for the smaller strength: "Each capsule contains: Lipase ... 10,000 PhEur units". - NICE NG85: Pancreatic cancer in adults - diagnosis and management (National Institute for Health and Care Excellence, 2018, updated 2019), recommendations 1.6.1 and 1.6.2 - https://www.nice.org.uk/guidance/ng85 ## Treatment metadata - Recognise, refer urgently, control the pain (Recognition & Referral) - Morphine — 30 mg — oral.solid - Pancreatin — oral.solid ## Complete treatment card ```text PANCREATIC CANCER Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class DD27 - condition scope only, no dose · NICE NG12: Suspected cancer: recognition and referral (recommendation 1.2.5) - https://www.ncbi.nlm.nih.gov/books/NBK555330/ · No dose - referral pathway, no medicine given in primary care · MSF Essential Drugs 2024 - morphine sustained- release (oral) · Pancreatic Cancer - disease-level clinical article (pancreatic-cancer- full.txt) · NICE NG85 recommendation 1.6.1 for the indication - "Offer enteric-coated pancreatin for people with unresectable pancreatic cancer" - with the dose and the strengths from Creon 25000 Capsules (pancreatin) SmPC sections 2 and 4.2 (eMC product 1168): "Each capsule contains pancreatin PhEur 300 mg equivalent to: Lipase ... 25,000 PhEur units" and "Initially one or two capsules during or immediately after each meal", and Creon 10000 Capsules SmPC section 2 (eMC product 1167) for the smaller strength: "Each capsule contains: Lipase ... 10,000 PhEur units". · NICE NG85: Pancreatic cancer in adults - diagnosis and management (National Institute for Health and Care Excellence, 2018, updated 2019), recommendations 1.6.1 and 1.6.2 - https://www.nice.org.uk/guidance/ng85 Review status: REVIEWED against 5 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Painless jaundice occurs in about half of patients, usually from a pancreatic head tumor blocking the common bile duct [jaundice] - Weight loss affects roughly 90 percent, and abdominal pain about 75 percent of patients [abdominal pain · weight loss] - Weakness, itching from bile salts, poor appetite, pale greasy stools, and dark urine can accompany the jaundice [itching · jaundice · pallor · poor appetite · steatorrhoea] - A recurrent deep vein thrombosis from the tumor's hypercoagulable state can be the clue that prompts a cancer workup - New-onset diabetes can be a presenting feature SIGNS - what you find (1) - A palpable, painless, distended gallbladder can be found on exam (Courvoisier sign) TESTS (6) - Liver enzymes, direct and total bilirubin, amylase, lipase, and the tumor markers CA 19-9 and CEA are typically elevated - Multidetector CT is about 77 percent accurate at predicting a tumor is resectable and 93 percent accurate at predicting it is not - MRI detects liver metastases with sensitivity near 100 percent, compared with about 80 percent for CT - Ultrasound poorly visualizes the pancreatic mass itself, often obscured by bowel gas, though it can show secondary bile duct dilation - Involvement of more than 180 degrees of the SMA or celiac axis marks a tumor as unresectable - Liver, peritoneal, omental, or distant lymph node spread makes the disease unresectable IF NOT THIS - what else fits (4) - Acute and chronic pancreatitis are on the differential before imaging and biopsy - Cholangitis and cholecystitis are on the differential - Cholangiocarcinoma and gastric cancer are on the differential - Peptic ulcer disease is on the differential Source StatPearls "Pancreatic Cancer" - disease-level clinical article Status traced to the source above Rx: Main treatment | Cancer pain - oral sustained-release opioid, specialist or palliative-care led | Exocrine insufficiency - enzyme replacement taken with food MAIN TREATMENT 1. RECOGNISE, REFER URGENTLY, CONTROL THE PAIN (RECOGNITION & REFERRAL)[1st line] Adult Pancreatic cancer usually presents late and carries a poor prognosis - the article puts 5-year survival at approximately 20% and holds that the outlook has barely moved despite advances in cancer therapy. The definitive management is surgical and it is a narrow window: an operation is the only route to cure, and only 20% of these cancers can still be resected by the time they are found. Which operation follows the site - a tumour in the head of the pancreas calls for a Whipple procedure, or pancreaticoduodenectomy, while one in the body or the tail calls for a distal resection. Systemic therapy is oncology's and is individualised, and NO chemotherapy dose is printed anywhere here: most patients judged possibly resectable should have chemotherapy before surgery, the two main regimens being FOLFIRINOX and gemcitabine with protein-bound paclitaxel. Refer urgently, and treat the pain while the referral runs. - Refer, with advice Peds Children follow the same pathway: recognise and refer. No primary-care medicine is implied. Source No dose - referral pathway, no medicine given in primary care Why Pancreatic cancer usually presents late and carries a poor prognosis - the article puts 5-year survival at approximately 20% and holds that the outlook has barely moved despite advances in cancer therapy. The definitive management is surgical and it is a narrow window: an operation is the only route to cure, and only 20% of these cancers can still be resected by the time they are found. Which operation follows the site - a tumour in the head of the pancreas calls for a Whipple procedure, or pancreaticoduodenectomy, while one in the body or the tail calls for a distal resection. Systemic therapy is oncology's and is individualised, and NO chemotherapy dose is printed anywhere here: most patients judged possibly resectable should have chemotherapy before surgery, the two main regimens being FOLFIRINOX and gemcitabine with protein-bound paclitaxel. Refer urgently, and treat the pain while the referral runs. Caution RED FLAG - The classic red-flag presentation a primary-care clinician should recognise is painless jaundice, weight loss (in ~90%), abdominal pain, pruritus, a palpable non- tender distended gallbladder (Courvoisier sign), alcoholic stools/dark urine, and unexplained recurrent DVT. RED FLAG - New (recent)-onset diabetes is itself a recognised presenting feature of pancreatic cancer that should prompt suspicion. Chemotherapy is prescribed by oncology and dosed by body surface area against the patient's blood counts, liver and renal function; no systemic cytotoxic dose is printed here, for anyone. The article's own warning about the stronger regimen is blunt: it is extremely toxic, and only a fit young patient can tolerate it. (Pancreatic Cancer - StatPearls - NCBI Bookshelf, NBK518996) Pain control and palliative care belong in the referral, not after it. Most pancreatic cancer is already advanced when it presents, and life expectancy at that point is very short, so a pain specialist and palliative care should be involved from the outset. (Pancreatic Cancer - StatPearls - NCBI Bookshelf, NBK518996) The article's own consultation list runs to palliative and supportive care, hospice, dietetics and nutrition, physiotherapy and occupational therapy. (Pancreatic Cancer - StatPearls - NCBI Bookshelf, NBK518996) Nutrition is part of the treatment, not an afterthought - the article stresses keeping nutrition to the front of the patient's care, since it bears on wound healing. The article names no drug for it; the pancreatin option below is sourced instead to NICE NG85, which names the indication in pancreatic cancer, and to the Creon label, which carries the dose. Obstructive jaundice has a mechanical answer, not a drug one. A biliary stent can relieve the jaundice in some cases. (Pancreatic Cancer - StatPearls - NCBI Bookshelf, NBK518996) This is interprofessional from day one. Where the disease is resectable, or borderline so, the chance of survival turns on close cooperation between surgery, medical and radiation oncology, pathology and radiology. (Pancreatic Cancer - StatPearls - NCBI Bookshelf, NBK518996) RED FLAG - New-onset diabetes in an older adult, or persistent epigastric or back pain. CANCER PAIN - ORAL SUSTAINED-RELEASE OPIOID, SPECIALIST OR PALLIATIVE-CARE LED 2. MORPHINE [1st line] Adult Sustained-release oral morphine (MSR). Starting straight on MSR, MSF gives an adult 30 mg every 12 hours, then raises the daily dose by 50% each day until the pain is controlled. It sets no ceiling - no standard dose exists, the right one being whatever relieves the pain, adjusted against regular assessment of pain intensity and of side effects. Where immediate-release morphine is available the preferred sequence is to titrate on it first - an adult takes 10 mg every 4 hours, with rescue doses of the same size between the scheduled ones, and the whole of the previous day's total re-divided every 24 hours - and then to switch across to the sustained-release form once pain is controlled. The effective daily dose is usually settled during that immediate-release phase, and the daily total stays the same across the switch. - For as long as the pain lasts; never stopped abruptly Peds Paediatric cancer pain is a specialist prescription. MSF's figures, both for a child over 6 months, are 0.5 mg/kg given every 12 hours on the sustained-release form and 0.15 mg/kg given every 4 hours on the immediate-release one. They are NOT wired into the weight calculator, because Egypt registers no paediatric oral morphine liquid and a sustained-release tablet cannot be divided to reach a child's dose. MSF's own warning is that tablets do not suit a young child at all, and that the oral solution should be used in their place. Source MSF Essential Drugs 2024 - morphine sustained-release (oral) Why The condition's own article calls pain control extremely important and ranks this among the most painful cancers there are, naming opioids, antiepileptics and corticosteroids as the classes that relieve it. The article names the class and no dose; the dose and the indication both come from the MSF monograph, whose Indications line for sustained- release oral morphine covers severe, persistent pain and cancer pain above all. Egypt registers one oral product, MST 30 mg Continus tablets (about 77 EGP for 10), which is exactly the strength MSF starts an adult on, plus 10 mg/mL and 20 mg/mL injectable ampoules. Antiepileptics and corticosteroids are named by the article as classes with no drug and no dose, so neither has a row. Caution MSF opens the morphine monograph with the warning that its adverse effects are many and can be severe, so a patient taking it is watched closely. CONTRAINDICATED - MSF: do not give it to a patient with severe respiratory impairment, or with decompensated liver disease. Do not start an elderly patient, or one with impaired kidneys or liver, on the sustained-release form. MSF says to begin with the immediate-release preparation (MIR) instead, and to halve the dose in the elderly and in renal or hepatic impairment. Never stop it abruptly. The dose follows the clinical response, and long-term treatment is never stopped at once - bring it down step by step, or the patient withdraws. Prescribe the laxative with the morphine, not after the constipation. MSF says to give a suitable laxative - lactulose, for instance - where the analgesic is going to run beyond 48 hours. Breakthrough pain has a rule, not a guess. A patient stable on the sustained-release morphine may still need rescue doses of the immediate-release form for episodic pain. Each rescue dose is 10% of the total daily sustained-release dose. Where the patient regularly needs more than 3 rescue doses a day, add the rescue doses up and raise the daily sustained-release dose by that amount. MSF says to give it with caution in head injury, raised intracranial pressure, respiratory impairment, uncontrolled epilepsy, and disorders of the urethra or prostate. Do not combine it with a mixed agonist-antagonist opioid - buprenorphine, nalbuphine or pentazocine - because they compete with it at the receptor. If respiratory depression happens: assisted ventilation, naloxone, or both - and then keep the patient under close observation for several hours. CONTROLLED DRUG. Morphine is a listed narcotic, and national regulations govern it. In Egypt that means the narcotic prescription rules apply and the supply is usually arranged through the oncology or palliative-care service; a clinic without that authority refers rather than prescribes. Egypt MST 30MG 10 CONTINUS TAB. MUP > MUNDIPH... 77.00 EGP EXOCRINE INSUFFICIENCY - ENZYME REPLACEMENT TAKEN WITH FOOD 3. PANCREATIN [1st line] Adult One or two capsules during or immediately after each meal, increased slowly against the symptoms. SmPC verbatim: "Initially one or two capsules during or immediately after each meal. Dose increases, if required, should be added slowly, with careful monitoring of response and symptomatology." A Creon 25000 capsule holds 25,000 units of lipase and a Creon 10000 capsule holds 10,000 units, so the meal dose is one or two capsules of whichever strength the pharmacy stocks. - Long-term, alongside the cancer treatment Peds No weight-based dose. Pancreatic cancer in childhood is an oncology problem and the enzyme dose is set by the treating team. Source NICE NG85 recommendation 1.6.1 for the indication - "Offer enteric-coated pancreatin for people with unresectable pancreatic cancer" - with the dose and the strengths from Creon 25000 Capsules (pancreatin) SmPC sections 2 and 4.2 (eMC product 1168): "Each capsule contains pancreatin PhEur 300 mg equivalent to: Lipase ... 25,000 PhEur units" and "Initially one or two capsules during or immediately after each meal", and Creon 10000 Capsules SmPC section 2 (eMC product 1167) for the smaller strength: "Each capsule contains: Lipase ... 10,000 PhEur units". Why Nutrition is part of the treatment of pancreatic cancer, and enzyme replacement is the part of it with a licensed product behind it. NICE names the indication in malignant disease: enteric-coated pancreatin is to be offered where the cancer cannot be resected, and to be considered on either side of a resection. NICE attaches no dose to it, so the dose and the capsule strengths come from the Creon label, whose own indication line is the broader treatment of pancreatic exocrine insufficiency, without naming a cause. The disease article agrees on the principle while naming no drug, holding that nutrition must stay at the front of a patient's care because it bears on how a wound heals. Caution Take the capsules with or immediately after food and swallow them whole. Crushing or chewing the minimicrospheres, or mixing them into food or fluid above pH 5.5, breaks the protective enteric coating; the enzymes are then released in the mouth, where they work less well and irritate the mucosa. Keep the patient properly hydrated throughout treatment with Creon 25000. Fibrosing colonopathy is the high-dose hazard. Strictures of the ileo-caecum and the large bowel have been reported in cystic fibrosis patients on high doses of pancreatin. As a precaution, any unusual abdominal symptom, or a change in one, should be assessed medically to exclude it - particularly above 10,000 units of lipase per kg per day. CONTRAINDICATED - a known hypersensitivity to porcine pancreatin, or to any excipient in the product. The enzymes are of pig origin, which some patients will want to be told before they start. Enzyme replacement treats the malabsorption, not the tumour. It does not delay the urgent referral or change the oncology plan. Egypt's one single-ingredient product, DYSPA-EAST, is labelled as 300 mg of pancreatin and declares no lipase unit content, so it cannot be counted capsule-for-capsule against Creon. Read the lipase units off whichever pack the pharmacy supplies before setting the number of capsules. Egypt DYSPA-EAST 300 MG 20 CAPS. WESTERN PHARM... 140.00 EGP (7.00/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)