Diet & Nutrition

Pancreatic Enzymes: Your Questions Answered...
Julie Meddles, RD, LD

The pancreas is a soft organ, which lies beneath the stomach and is connected to the small intestine. It consists of a cluster of grapelike cells that produce both hormones and pancreatic secretions. The pancreas normally secretes about 8 cups into the small intestine daily. Most of this secretion occurs after meals and contains enzymes that aid in the digestion or breakdown of all three major components of food: proteins, carbohydrates and fats. Pancreatic juice also helps neutralize the acidic gastric juice emptied from the stomach to the duodenum.

The following are different components of pancreatic enzymes - lipase, protease and amylase. Lipase, along with bile, digests fat into fatty acids and glycerol, which can be absorbed by the body and used. A shortage of lipase results in malabsorption of fats and fat-soluble vitamins. Protease, also called proteolytic enzyme, digests or breaks down proteins into amino acids and peptides (small groups of amino acids). Incomplete digestion of proteins can result in allergies or the formation of toxic substances. Protease helps keep the intestine free of parasites such as bacteria, yeast and protozoa. Lack of proteases or other digestive secretions increases the risk of having an intestinal infection. Amylase is required for digestion of carbohydrates. Amylase is also secreted by the salivary glands and is present in saliva. Amylase breaks down starch to sugars which are more easily absorbed.

Pancreatic insufficiency, decreased output of pancreatic enzymes, is associated with abdominal pain, bloating, gas, indigestion and the passing of undigested food in the stool. Mild pancreatic insufficiency is fairly common, especially in older adults. Pancreatic insufficiency can also play a major role in many cases of food allergies.

Doctors sometimes prescribe digestive enzymes, including pancreatic enzymes, to improve digestion and absorption of food in several conditions that cause malabsorption. Some of these conditions are: pancreatic insufficiency, status post surgery of the pancreas (ie, Whipple procedure), removal of the pancreas (ie, total pancreatectomy), pancreatic obstruction due to stone formation in the pancreatic/biliary duct, pancreatic/duodenal tumors or ductal narrowing and cystic fibrosis.

Pancreatic insufficiency is common in pancreatic cancer patients and may cause vague abdominal discomfort, pain, abdominal distention, excessive flatus (gas), belching, diarrhea, steatorrhea (fat indigestion) and weight loss. Pancreatic enzyme replacement therapy should be considered for these patients. It has been shown that a combination of pancreatic enzyme replacement therapy, nutritional counseling and biliary drainage can prevent weight loss in patients with unresectable cancer in the head of the pancreas with pancreatic duct obstruction.

Reportedly about 25% of patients who have the Whipple procedure, the most commonly used operation for removing a pancreatic tumor, may suffer from malabsorption. Fat absorption usually cannot be restored to normal, but the goal should be to eliminate diarrhea, restore adequate nutrition and prevent weight loss. A dose of 30,000-40,000 units of lipase at each meal could achieve these results.

Prescription pancreatic enzymes as well as several non-prescription pancreatic enzymes are available. The amounts of enzymes in each can have huge variations. The recommended type and dose of enzymes is individualized for each person. It is important to discuss with your physician the appropriate type and dose. The following are names of pancreatic enzymes which contain varying amounts of lipase, protease and amylase.

Pancrelipase (porcine source):
Prescription: Pancrease, Pancrease MT 4, 10, 16, 20, or 25 Capsules, Lipram, Protilase Capsules, Cotazym-S or Cotazym Capsules, Ku-Zyme HP Capsules, Zymase Capsules, Ultrase and Ultrase MT 12 or 20 Capsules, Viokase Tablets or Powder, Creon 10 or 20 Capsules.

Pancreatin (bovine, porcine or vegetable source):
Non-prescription: Pancrezyme 4X Tablets, 4X Pancreatin 600mg Tablets, 8X Pancreatin 900mg Tablets, Hi-Vegi-Lip Tablets.

Although the dose is individualized for each patient, some recommendations are common for the optimal way to take the pancreatic enzymes.

• If feasible, the total dose taken with food should be dispersed equally before, during and after the meal or snack and should be taken with fluids.

• The smallest effective dose should be used and the dosage should be adjusted according to the severity of the pancreatic insufficiency and symptoms. It is recommended that therapy be initiated at low dose, followed by titration to the effective dose. The goal should be to minimize the symptoms and maintain good nutritional status. If a meal intake increases, pancreatic enzymes may need to be increased to accommodate the increase in food.

• Some supplements have a special coating to prevent breakdown in the stomach. The tablets should not be crushed or chewed. Intact capsules should be swallowed with liquid at mealtimes.

• If swallowing a capsule is difficult, open the capsule and add the microspheres to a small quantity of soft food (applesauce, gelatin, apricot, banana and sweet potatoes) that does not require chewing and can be swallowed immediately and not retained in the mouth. Certain enzymes present in pancrelipase, when retained in the mouth, may begin to digest the mucous membranes and cause irritation/ulcerations of the mouth, lips and tongue.

• The capsules should not be taken with milk, custard, ice cream and many other dairy products because the higher pH of these foods may dissolve the enteric coating and destroy the enzyme activity.

Discontinue use of pancreatic enzymes if any signs of hypersensitivity appear. Any person with allergies to beef, pork, pineapple or papaya should not use enzymes as they are prepared with these foods. Excessive doses may cause nausea, abdominal cramps or diarrhea. Possible drug interactions exist with antacids and iron.

In summary, pancreatic enzyme replacement may help prevent weight loss and control symptoms of malabsorption, such as gas, bloating, fullness and diarrhea. In general, as long as it is not contraindicated, a trial of pancreatic enzyme replacement is acceptable. The decision to use pancreatic enzymes as well as any change in dose or brand of enzyme should be made cautiously and only under medical supervision.

The Diet & Nutrition column is sponsored by Ross Products.

Julie Meddles, RD, LD writes PanCAN's "Diet & Nutrition" column in our quarterly newsletter. Julie is currently the Senior Dietitian at University Hospitals East in Columbus, Ohio and brings with her ten years of professional experience in the field of nutrition. She has held various roles in the Oncology Nutrition Dietetic Practice Group and currently she holds the position of Chair-elect. If you have a diet and nutrition question, please email it to medinfo@pancan.org or call one of our PALS Associates at 877-272-6226.