PANCREATIC ENZYMES

What are pancreatic enzymes?

Pancreatic enzymes are natural chemicals that help break down fats, proteins, and carbohydrates.  A normally functioning pancreas secretes about 8 cups of fluid, called pancreatic juice, daily into the duodenum, the portion of the small intestine that connects with the stomach.  This fluid contains pancreatic enzymes and helps neutralize stomach acid as it enters the small intestine. 

Types of Pancreatic Enzymes and Their Effects 

Reasons to Take Pancreatic Enzymes

Pancreatic insufficiency is the inability of the pancreas to secrete enzymes needed for digestion.   Having an insufficient amount of pancreatic enzymes is very common among people with pancreatic cancer.  When the pancreas does not produce enough enzymes to break down food, pancreatic enzyme products are needed.  Doctors sometimes prescribe digestive enzymes, including pancreatic enzymes, to patients who have conditions that cause poor digestion. 

Some of these conditions are:

• following the Whipple procedure
• following a total pancreatectomy (complete removal of the pancreas)
• blockage or narrowing of the pancreatic or biliary duct (the tubes that carry pancreatic juice or bile)
• pancreatic or duodenal tumors
• cystic fibrosis
• pancreatitis

Pancreatic insufficiency may cause feelings of indigestion, cramping after meals, large amounts of gas, foul smelling gas or stools, floating or greasy/fatty stools, frequent stools, loose stools and weight loss.  Patients with these symptoms should consider pancreatic enzyme supplements. 

About 25% of patients who have the Whipple procedure, the most commonly used operation for removing a pancreatic tumor, will have malabsorption.  Patients who have radiation therapy along with the Whipple procedure are much more likely to have malabsorption.  Fat absorption usually does not return to normal in these patients even with enzyme supplementation.  In this case, the goal is to eliminate diarrhea, restore adequate nutrition and prevent weight loss. 

A dose of enzyme supplements containing 30,000 - 40,000 lipase units at each meal may help achieve these results.

In patients with advanced cancer in the head of the pancreas that cannot be surgically removed, bile duct and/or pancreatic duct obstructions are common.  For these patients, a combination of pancreatic enzyme replacement therapy, nutritional counseling and drainage of the bile duct can prevent weight loss and improve symptoms.

Supplemental pancreatic enzymes are available in prescription and non-prescription forms. The different brands of pancreatic enzyme products are not identical. The United States Food and Drug Administration (FDA) has mandated that all pancreatic enzyme products obtain FDA approval by April 2010 to ensure effectiveness, safety and manufacturing consistency. In order to gain FDA approval, companies have to prove that their pancreatic enzyme product is effective, safe and manufactured consistently from one batch to the next.

Over-the-counter pancreatic enzyme products are available without a prescription.  Since they are classified as dietary supplements rather than drugs, the FDA regulates them under a different set of regulations.  While manufacturers are required to ensure the safety of their products, there are no controls on manufacturing consistency from one batch to the next.  Therefore, these products are not recommended for use in patients with pancreatic cancer.

The recommended type and dosage of pancreatic enzymes must be individualized for each person. Most people start by taking 8,000 - 12,000 lipase units with snacks and 16,000 - 36,000 lipase units with meals.  Some individuals adapt to different doses of enzymes throughout their care. It is important to discuss with a doctor or dietitian the appropriate type and dose of pancreatic enzymes at regular visits.

Prescription Pancreatic Enzymes

All prescription enzymes come from a porcine (from a pig) source. If a person has allergies to porcine products, consult a doctor and/or dietitian for alternative options.

Approved by the United States FDA:

• Creon® capsules
• Pancreaze™ capsules
• Zenpep™ capsules
  

*Pending approval by the United States FDA:

• Pancrecarb® capsules
• Ultrase® tablets
• Viokase® tablets or powder

*Although the FDA has not approved these products yet, they may be acceptable for use while they go through the approval process.

For more information about the FDA and pancreatic enzymes, visit the FDA website by clicking here or call a PALS Associate at the Pancreatic Cancer Action Network toll free at 877-272-6226 or email pals@pancan.org.  PALS Associates are available M-F 7am-5pm Pacific Time.

Taking Pancreatic Enzymes

The doctor may prescribe an acid-reducing medication to help improve the effectiveness of some pancreatic enzyme products. Acid reducing medications include proton pump inhibitors, such as esomeprazole (Nexium®) or omeprazole (Prilosec®), and H2 blockers, such as famotidine (Pepcid®), cimetidine (Tagamet®), and ranitidine (Zantac®).

Tips to obtain the best results from pancreatic enzymes:

• Take enzymes with every meal or snack that contains fat, especially meat, dairy, bread and desserts.

• Start with the smallest dose necessary. Adjust according to the severity of the pancreatic insufficiency. Further alterations may be needed from time to time.

• Take the enzymes at the beginning of the meal or snack. This is very important for proper enzyme functioning. When taking multiple enzymes, take some at the beginning of the meal and the rest at various points throughout the meal. Enzymes generally do not work well if forgotten and only taken at the end of the meal.

• Swallow intact tablets and capsules with liquid at mealtimes. Some enzyme supplements have a special coating to prevent breakdown in the stomach. The tablets should not be crushed or chewed unless you are directed by a member of your medical team.

• If held in the mouth for a length of time, certain pancreatic enzyme products may begin to digest the mucous membranes and cause irritation. This can lead to sores on the mouth, lips and tongue. If swallowing a capsule is difficult, open the capsule and add its contents to a spoonful of soft food that does not require chewing and can be swallowed immediately. Some recommended foods are applesauce, gelatin, pureed apricot, banana or sweet potatoes.

• Pancreatic enzymes may have reduced effectiveness if taken at the same time as calcium- or magnesium-containing antacids, such as Maalox®, Mylanta®, Rolaids® and others.

• To promote enzyme function, do not mix the contents of capsules (microspheres) with milk, custard, ice cream or other dairy products before swallowing. These foods have a higher pH that may dissolve the microspheres' coating and destroy enzyme activity before they reach the stomach.

• Use enzymes prior to their expiration date.  They may become less effective as they get older.

Side Effects of Pancreatic Enzymes

The information and services provided by the Pancreatic Cancer Action Network, Inc. are for informational purposes only.  The information and services are not intended to be substitutes for professional medical advice, diagnosis or treatment.  If you are ill, or suspect that you are ill, see a doctor immediately!  The Pancreatic Cancer Action Network does not recommend nor endorse any specific physicians, products or treatments even though they may be mentioned on this site.  100902