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Pancreatic Enzyme Replacement Therapy
The information provided here should not be treated as a medical opinion. You should speak to your surgeon, oncologist, gastroenterologist, dietician, specialist nurse or other medical professional for guidance and advice on taking pancreatic enzymes.
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The pancreas helps to digest your food by producing secretions (pancreatic juice) containing enzymes that aid in the digestion and breakdown of the major components of food and also by helping to neutralize acidic gastric juice.
Pancreatic insufficiency, that is decreased output of the pancreatic enzymes lipase (responsible for digestion of fat), protease (responsible for digestion of proteins) and amylase (responsible for digestion of carbohydate), is common in pancreatic cancer patients, especially after surgery.
This means that the patient isn't benefitting from all the food that is being eaten and may lose weight despite eating well and have symptoms caused by the lack of absorption of fat, protein, carbohydrates and vitamins.
Pancreatic insufficiency may cause vague abdominal discomfort, pain, abdominal distention, excessive flatus (gas), belching, diarrhoea, steatorrhoea (fat indigestion) and weight loss.
Apart from weight loss one of the most obvious symptoms of pancreatic insufficiency is steatorrhoea. The lack of digestion of fat causes steatorrhoea which is pale, greasy stools that can be foul smelling and float and be difficult to flush away.
Pancreatic enzyme replacement therapy should be considered if you have these symptoms. A good article on pancreatic enzymes and replacement therapy is available from the PanCAN pages. It includes information on brands of prescription replacement pancreatic enzymes available in the USA. Brands that are used in the UK are listed in section below.
It is obvious that pancreatic insufficiency is likely to be a problem with patients who have undergone surgery to have part of the pancreas removed. However most non-surgical cancer patients will have a blocked or partially blocked pancreatic duct and so are also likely to have some need of enzyme replacement therapy. The benefit to non-surgical patients has been shown in a trial reported by Bruno at el 1998 (see references below).
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Initially you are likely to be told to try one or two capsules (or other forms) of low doseage enzymes with meals.
You will then work with your medical team to adjust the amount you are taking until there is some control of the symptoms such as diarrhoea and steatorrhoea. The different brands of replacment enzymes contain differing amounts of enzymes and your medical professional will work with you to find the amount that you need to improve your digestion of food.
The amount of pancreatic enzymes required will vary with amount of food eaten and may need to be increased with larger meals. You will need to take them with snacks as well as main meals.
Replacement pancreatic enzymes are available in different formulations and doseages. So a patient needing a large quantity of enzymes per meal can take a smaller number of high doseage capsules or tablets.
The number of capsules you need will also be affected by how much acid your stomach produces, and many doctors prescribe medication to reduce the acid which should make the enzymes more effective.
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In order to help digestion the enzymes must mix with the food in the stomach, and pass from there to the small bowel together with the food. The enzymes will be inactivated by acid and heat so should be taken with meals and not mixed in hot foods.
If your specialist has advised you to take pancreatic enzymes they should be taken with meals and with any snack, adjusting the number of capsules to match the amount of food eaten at any one time.
Unfortunately there is no agreement amongst specialists about when it is best to take the replacement enzymes with your food. Some professionals will tell you to take the enzymes with your meal. Others will advise you to take your enzyme capsules before eating, 15-20 minutes before if possible.
General guidance is that they should be taken throughout the meal or at the beginning, during and at the end of the meal so that they mix as much as they can with the food and travel along the digestive system with the food so that they can be the most effective at digesting the food.
The most important thing is that if your specialist has advised you to take them that you remember to take them whenever you eat.
The changes in the way your stomach works after surgery also make it difficult to be dogmatic about how much and when to take your enzymes. If you are still having problems with the symptoms of pancreatic insufficiency listed above you may need to discuss with your doctor or nurse whether you should try taking them at different times relative to your meal.
Sometimes pancreatic function recovers with time, but this treatment often needs to be life-long.
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A few patients have problems with taking pancreatic enzymes. The Patient UK web-site provides some guidance on pancreatin including possible side-effects. Further information is available from the electronic medicines compendium by entering Creon, Pancrease, Nutrizym or Pancrex in the quick search on the "find a medicine" page.
Some patients can benefit by changing to a different formulation.
Some people feel bloated when they take pancreatic enzymes however many people have pain/bloating/discomfort as a result of insufficiency which gets better with enzymes.
If a patient is having problems with bloating it may be a problem with when the enzymes are taken relative to food, taking them with meals or just after meals may help. Discuss this with your medical team.
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Pancreatic enzyme supplements are also called pancreatin which is a combination of pancreatic enzymes that are normally produced naturally by the body.
Pancreatin is available in capsule, powder, granule and tablet form. It is also sometimes known as: Creon; Nutrizym; Pancrease; Pancrex; Pancrex V. You may notice the use of any of these names on the packaging of your medicine. There are different amounts of protease, amylase and lipase in most of the products.
Replacement pancreatic enzymes are available in different formulations and doseages. For instance Creon is available in doseages of 10000, 25000 and 40000 units of lipase per capsule. So a patient needing a large quantity of enzymes per meal can take a smaller number of high doseage capsules
(up to five or six capsules, around 240,000 units of lipase, with meals if necessary). Some patients, eg those who have had surgery to remove part or all of the pancreas, may need to take up to 20-30 of the high doseage capsules a day (ie 1,000,000 units of lipase).
Products available include:
information from Pancreatitis Supporters' Network
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