Pancreatic Enzyme Replacement Therapy (PERT)
What are pancreatic enzyme supplements?
Pancreatic enzyme replacement therapy involves taking the digestive enzymes you need in the form of a tablet (capsule). 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 50,000 to 75,000 units of lipase with a meal and 25,000 units with a snack.
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 will recommend the amount to take. You may be started on 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. All food 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.
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 2 courses, or one lasting more than half an hour, you may need to take half of your enzymes at the beginning and the other half in the middle of your meal.
When NOT to take enzyme supplements:
- On an empty stomach.
- With drinks that contain less than half milk – such as tea, non-milky coffee, fruit squashes and fizzy drinks.
- If you eat small quantities of fruit, vegetables, dried fruit, fat-free sweets (jelly babies, wine gums, mints).
- If you take a very small quantity of food such as an individual chocolate/square of chocolate or a small plain biscuit.
You need to take enzymes whenever you eat a meal or a snack. Take them as you start to eat your meal so they mix with the food in the stomach.
How enzyme supplements work?
The pancreatic enzyme capsule is swallowed and, along with food, travels down to the stomach. Once in the stomach, the capsule is broken down and the granules which contain the enzyme are released.
The enzymes mix with food and become activated in the small intestine, breaking down food allowing the nutrients to be absorbed.
Things to remember:
- Pancreatic enzymes are damaged at high temperatures.
- Store your enzymes at room temperature (they don’t need to be refrigerated).
- Do not store enzymes in warm places such as near radiators, in cars and do not carry enzymes in trouser pockets.
- Never mix enzymes with hot drinks.
- Carry the number of capsules you need in a pill box or small container so you do not have to carry the whole bottle with you.
Do I have to restrict my diet?
No, 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.
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.
Remember – Pancreatic enzymes can be damaged by heat so do not store near radiators, in your car or in trouser pockets.
For how long will I have to take pancreatic enzymes?
If your pancreas has been damaged by cancer or you have had all of it removed through surgery, you will need to take pancreatic enzymes for the rest of your life. If you have had surgery to remove part of the pancreas, your pancreatic function may improve, but this is unlikely. The majority of people will need to take these enzymes for the rest of their life. After surgery sometimes pancreatic function can decline and the dose may need to be increased.
Can I take too many pancreatic enzymes?
No, what your body doesn’t need to break down the food you eat will be excreted in your next bowel movement. Occasionally this may cause a little burning around the anus. Speak to your doctor if this occurs.
What will happen if I forget to take my pancreatic enzymes?
Sometimes it is difficult to remember to take your pancreatic enzymes but if you do not take them, your symptoms will not go away and may even get worse. If you stop taking them for long periods of time, then you will not be absorbing important vitamins that your body needs and you may lose weight. This may affect your ability to undergo some treatments such as chemotherapy.
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 following:
“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.”