What is the current standard of care for exocrine pancreatic insufficiency in dogs?

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The standard of care for canine exocrine pancreatic insufficiency (EPI) is lifelong pancreatic enzyme replacement therapy (PERT) combined with a low-residue, moderate-fat diet, cobalamin supplementation when indicated, and management of concurrent dysbiosis or enteropathy in non-responders.12 Diagnosis is confirmed by serum canine trypsin-like immunoreactivity (cTLI) at a cutoff of ≤2.5 µg/L, using a species-specific immunoassay that directly reflects functional pancreatic acinar mass.14 Clinical EPI is classified at cTLI <2.0 µg/L, and subclinical EPI at 2.0–5.0 µg/L, against a reference interval of 5.2–35 µg/L.911 PERT is the primary treatment and is required for life. Commercially available products are of animal origin and contain pancreatin — an extract of porcine pancreas providing lipase, amylase, and protease.10 Enteric-coated and uncoated formulations are both used; no difference in fecal fat reduction has been demonstrated between them in dogs with EPI.4 Response to initial treatment is good in 60–64% of dogs, partial in 17–19%, and poor in 17–23%.4 Dietary management targets a low-residue diet with moderate fat content in dogs.1 The 2021 AAHA Nutrition and Weight Management Guidelines recommend a low-fat diet for dogs with EPI, with the caveat that fat recommendations may depend on baseline intake and degree of hyperlipidemia.6 In most cases, no specific diet is required beyond appropriate enzyme supplementation, but additional fiber supplementation is warranted for persistent soft stool.6 Cobalamin supplementation is indicated when serum cobalamin is low. More than 80% of dogs with EPI have abnormally low serum cobalamin, and low concentrations are associated with poor clinical response and outcome.4 Oral cyanocobalamin at 0.25–1.0 mg daily (dose selected by body weight) normalizes serum cobalamin — median concentrations rise from 188 ng/L to 1000 ng/L after a median of 41 days of supplementation — and is an effective alternative to parenteral administra