Pancreatic Enzymes

The pancreas serves two functions: producing hormones and secreting digestive enzymes. A normally functioning pancreas secretes about 8 cups of fluid daily into the portion of the small intestine that connects with the stomach, called the duodenum. This fluid, referred to as pancreatic juice, helps neutralize stomach acid as it enters the small intestine. It also contains pancreatic enzymes.

Pancreatic enzymes help to break down fats, proteins, and carbohydrates. Pancreatic enzyme supplements are necessary when the pancreas does not produce enough enzymes on its own to break down food. Having an insufficient amount of pancreatic enzymes is very common among those with pancreatic cancer. For those who have had the Whipple procedure to surgically remove a pancreatic tumor, malabsorption is an issue since fat absorption cannot be completely restored to normal.

Types of Pancreatic Enzymes and Their Effects

Reasons to Take Pancreatic Enzymes

Doctors sometimes prescribe digestive enzymes, including pancreatic enzymes, to improve digestion and absorption of food in conditions that cause poor absorption. Some of these conditions are:

•   pancreatic insufficiency
•   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

Pancreatic insufficiency is the inability of the pancreas to secrete the enzymes needed for digestion. Mild forms of pancreatic insufficiency are fairly common, especially in older adults, and can also play a major role in many cases of food allergies. It is common in pancreatic cancer patients and 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. Pancreatic enzyme supplements should be considered for these patients.

The Whipple procedure is the most commonly used operation for removing a pancreatic tumor. About 25% of patients who have the Whipple procedure suffer from malabsorption. Fat absorption usually cannot be restored to normal in these patients. 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 units of lipase at each meal may help achieve these results.

In patients with advanced cancer in the head of the pancreas with pancreatic duct obstruction that cannot be surgically removed, a combination of pancreatic enzyme replacement therapy, nutritional counseling, and drainage of the bile duct can prevent weight loss.

Sources of Pancreatic Enzymes

Supplemental pancreatic enzymes are available in both prescription and non-prescription forms. The amount of each enzyme varies greatly between the different brands of tablets. The United States Food and Drug Administration (FDA) has mandated that all pancreatic insufficiency drugs obtain FDA approval by 2008 to help regulate formulations, dosage, and potency of these products. However, current production of enzyme supplements is not standardized; therefore, one brand may not be equivalent to another.

The recommended type and dosage of pancreatic enzymes must be individualized for each person. When the patient finds a brand that works, it is suggested that he or she stick with that brand. Most people start by taking one pill with snacks and two with meals and increase or decrease the dose as needed. Some individuals may 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.

Available by prescription – All prescription enzymes come from a porcine source. If the patient has allergies to porcine products, consult a doctor and/or dietitian for alternative options.

Cotazym capsules

Creon® capsules

Ku-Zyme® HP capsules

Lipram® capsules

Palcaps capsules (generic brand)

Pancrease® capsules

Pancrecarb® capsules

Pancron® capsules

Pangestyme® capsules

Protilase® capsules

Ultrase® capsules

Viokase® tablets or powder

Zymase capsules

Available without a prescription:

Hi-Vegi-Lip tablets (vegetable source)

Pancreatin tablets (bovine, porcine, or vegetable source)

Pancrezyme tablets (porcine source)

Pancreatin tablets (porcine source)

Veg-Pancreatin (vegetable source)

Taking Pancreatic Enzymes

An acid-reducing medication may be prescribed by the doctor to help improve the effectiveness of pancreatic enzyme supplements. Acid reducing medications include proton pump inhibitors, such as Nexium® or Prevacid®, and H2 blockers, such as Pepcid®, Tagamet®, and Zantac®. Tips to obtain the best results from pancreatic enzymes:

•   Take enzymes with every meal or snack that contains fat, especially meat, dairy, bread, snacks, 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, they should be taken at the beginning, middle, and end of the meal. Enzymes generally do not work well if forgotten and only taken at the end of the meal.
•   Swallow intact tablets 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.
•   Certain enzymes that are present in pancrelipase may begin to digest the mucous membranes and cause irritation if retained in the mouth. This can lead to ulcerations of the mouth, lips, and tongue. If swallowing a capsule is difficult, open the capsule and add the entire capsule of microspheres 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.
•   Promote enzyme function by not mixing the open capsules with milk, custard, ice cream, and other dairy products. These foods have a higher pH that may dissolve the capsule's coating and destroy enzyme activity before they reach the stomach.
•   Pancreatic enzymes may have reduced effectiveness if taken with calcium- or magnesium-containing antacids.

Side Effects of Pancreatic Enzymes

The most common side-effect of pancreatic enzymes is constipation. However, it is possible for enzymes to cause nausea, abdominal cramps, or diarrhea, though these symptoms are uncommon.

Discontinue the use of pancreatic enzymes if any signs of hypersensitivity or allergic reaction appear. Beef, pork, pineapple, and/or papaya may all be used in the preparation of enzymes. Therefore, individuals with allergies to any of these foods should work with their pharmacist and doctor to find an appropriate enzyme preparation. In addition, pancreatic enzymes may influence the effectiveness of some diabetic medications, and possible drug interactions exist with antacids and iron. Notify the patient's doctor and registered dietitian of all current medications and medical conditions while discussing the use of pancreatic enzymes.

If taken properly, pancreatic enzymes can help prevent weight loss and control symptoms associated with pancreatic enzyme insufficiency. Ask the patient's doctor to prescribe the proper pancreatic enzymes.

This information has been taken from Diet & Nutrition: Nutritional Concerns with Pancreatic Cancer, a booklet produced by the Pancreatic Cancer Action Network. To receive a complimentary copy, please contact a Patient and Liaison Services (PALS) Associate toll free at (877) 272-6226 or email pals@pancan.org. PALS Associates are available Monday through Friday 8:00 am to 5:00 pm Pacific Time.