Pancreatic Enzyme Replacement Therapy (PERT)

About Pancreatic Enzyme Replacement therapy

All enzyme supplements contain Pancreatin- a mixture of pancreatic enzymes, lipase, amylase and protease. These assist the digestion of fat, carbohydrates and proteins.

Enzyme doses vary from person to person. A starting dose is around 50,000 to 75,000 units of lipase with a meal and 25,000 units with a snack.

The different pancreatic enzyme preparations include Creon®, Nutrizym®, Pancrease® and Pancrex®. They commonly come in 2 capsule sizes; 10,000 unit (mainly used in children) and 25,000-unit capsules. Each capsule has a different number or letter following the name to indicate the strength of the dose.

Most adults take either 2 or 4 of the 25,000-unit capsules per meal. Do not be alarmed by the high capsule units — the number relates to the amount of lipase units it contains. A healthy pancreas will release about 720,000 lipase units during every meal.

Pancreatic enzyme supplements are extracted from pig pancreas glands and there is currently no alternative to using pork products. However, it is important to know that for those who may have a religious objection to the ingestion of pork products, special dispensation to allow these products has been granted by religious organisations as they are a medicine.

How should I take enzyme supplements?

You will need to take enough enzymes to allow your body to break down your food. Your dietitian, doctor or nurse specialist will recommend the amount to take. You may be given a low dose at first which will increase gradually until your symptoms are under control.

Capsules should be taken with all food directly – i.e. with the first mouthful of food. This includes meals, snacks and milky drinks including milk based nutritional supplement drinks such as over-the-counter shakes, homemade or prescription drinks. Your doctor and dietitian will advise you. It is important that you spread the capsules out throughout
your meal.

If you don’t take your enzymes with every meal or snack, the symptoms of malabsorption may return.

Capsules must be swallowed with a cold drink. Swallowing them with a hot drink can make them less effective as enzymes are damaged at high temperatures.The capsules should be swallowed whole and must not be crushed or chewed. If you are having a large meal with more than two courses, or one lasting more than half an hour, you will need to take your enzymes with each course.

When NOT to take enzyme supplements

• On an empty stomach
• With drinks that contain less than half milk like tea, squash and fizzy drinks
• If you eat small quantities of fruit, vegetables, dried fruit and fat free sweets like wine gums or mints
• If you eat a very small quantity of food such as an individual chocolate or biscuit
• Can I vary the dose of the pancreatic enzymes myself?

While your doctor or dietitian will discuss what strength dose is best for you. You will be the best judge of your symptoms, so it may be appropriate for you to alter the dose yourself. For example, if you are experiencing persistent loose bowel motions and are failing to gain weight, you may want to increase your dose.

If you are eating a meal that is high in fat such as a takeaway curry or fish and chips, you will need to take more capsules. Your dietitian will explain how to do this.

If you are at all uncertain about what dose you should be taking, contact your doctor or dietitian.

It is not necessary to restrict your diet, but it is important to follow a balanced diet to help you maintain weight or gain weight. Some people find certain foods, especially fatty foods, may cause bowel motions to be smelly and loose. In this case, it may be necessary to adjust the dose of your pancreatic enzyme.

Foods higher in fat can be beneficial for those who have lost a lot of weight or are below an ideal weight. Your dietitian can give you advice on the diet that is best for you.

Are there any side effects?

As some people will experience side effects from enzyme replacement, it is important that you read the medicine information leaflet produced by the manufacturers. The most frequent side effects are constipation, diarrhoea, nausea, and abdominal discomfort. These usually settle over time or, as the manufacturers use different coatings, it may be worth switching to a different brand of enzyme. Let your doctor know if you experience severe diarrhoea.

What if I have difficulty swallowing the capsules?

In this case it is possible to open the capsule and mix the granules (do not crush them) into an acidic fruit puree such as apple sauce or with yoghurt. This mixture needs to be swallowed straight away, without chewing.
It could be helpful to have a cold drink after this to help flush down any remaining enzyme granules and eating a snack or meal straight away.
It is also possible to ask for a lower-dose capsule which is smaller and easier to swallow. However, in order to get your required dose, you will need to take more of them.

My religion restricts me from eating pork, so can I still take pancreatic enzymes?

Currently, all enzyme replacement products are produced from pork-derived ingredients and no alternatives are available. However, pancreatic enzymes have been approved for use by Jewish patients by the Chief Rabbi. For Muslim patients, Dr Abdul Hamid Mohamed, London Central Mosque Trust, has advised the folowing:

“If, and only if, no other medicines than the ones containing prohibited substances are suitable to cure the illness or disease in the opinion of the physician, then the medicine containing the prohibited substance should be prescribed and taken by the patient.”