Understanding Pancreatic Enzymes

Definition of an enzyme:

(EN-zime) protein made by the body that brings about a chemical reaction, for example, the enzymes produced by the gut to aid digestion.[1]

One of the functions of the pancreas is to secrete enzymes into the small intestine. Enzymes are critical to the digestion process, because they break down food. In persons with cystic fibrosis, the pancreas is unable to release enzymes because the ducts (i.e. passageways) are blocked by thick sticky mucus.

In order for the body to make use of food, it has to have a way to absorb the nutrients from that food. Protein, carbohydrates and fat are the three sources of calories in food. There are specific types of enzymes that break down each of these. Amylase helps the body absorb carbohydrates. Lipase is effective in breaking down lipids and fats. Protease breaks down protein.

People with CF are prescribed one of the following brands of supplemental enzymes:

Creon ®, Ultrase ®, Ultrase ® Viokase ®, Pacreacarb ® MS, Pancrease ®, Pancrease ® MT

No matter which type of supplemental enzymes a person takes, they all contain a mixture of lipase, protease and amylase. The only difference is in how many units of each is contained in each capsule. The capsule is filled with tiny beads—these are the enzymes.

Enzyme supplements are sold as “enteric coated capsules.” Enteric coating means that the capsule is designed to break down in the small intestine, and not the stomach. This is so that the beads of protease, amylase and lipase are released in a way that mimics the body’s natural digestion process.

The number of enzyme capsules a person must take varies depending on the type of food being eaten. The Cystic Fibrosis Foundation states that foods containing only simple carbohydrates and no fat, do not need to be accompanied by enzymes.[2] These foods include jelly beans, popsicles, tea and coffee.

The strength of a supplemental enzyme (and sometimes its name) is derived from the number of lipase units. Below is a list comparing amounts of protease, amylase and lipase in some name-brand enzyme supplements. For additional information, check the product manufacturers websites listed at the end of this article.

CREON 10

Lipase 10,000 USP units
Protease 37,500 USP units
Amylase 33,200 USP units

PANCREACARB MS 8

Lipase 8,000 USP units
Protease 45,000 USP units
Amylase 40,000 USP units

ULTRASE MT 20

Lipase 20,000 USP units
Protease 65, 000 USP units
Amylase 65,000 USP units

Determining which type of enzyme supplements to take and how many capsules requires the assistance of a nutritionist or dietitian. This may require a 3 day fecal fat study. During the study, you will be asked to follow a strict diet that has a minimal amount of fat calories. A stool sample will then be collected which will be analyzed to see how much fat is not being absorbed by the body. This information will enable the dietitian to calculate how many units of lipase, protease and amylase should be taken with meals.

There is no “one-size-fits-all” solution when it comes to supplemental enzymes. However, supplements are required in people with CF who demonstrate pancreatic insufficiency. There are many ways to adjust the dosages of enzymes. There are differences in opinion as to whether they should be taken with a meal, before a meal, throughout the meal, or after the meal. Based on the way supplemental enzymes are designed to mimic pancreatic enzymes and their release into the small intestine, it seems to make the most sense to take supplements before the meal. That way, they have been broken down, and will sit in the gut awaiting food that will travel from the stomach to the intestines.

No matter which type of enzymes have been prescribed, it is important to keep your CF doctor informed about how well you’re eating and moving your bowels. A mismatch between food habits and enzyme dosages could result in just a stomach ache, or a more serious bowel obstruction.

Most importantly, without enzymes, the body would not be able to absorb the nutrients and calories it needs to function and grow. Good nutrition is essential to overall health for a person with CF. In fact, studies have demonstrated a link between higher lung function and higher nutritional status.

Like other medications, there are some side effects that could occur by taking enzyme supplements. Mostly these include stomach ache, possible bowel blockages, or bloating. However, these are easily avoided by taking the correct dosage and checking in frequently with the nutritionist at the CF clinic.

Although there are generic enzyme supplements available, the Cystic Fibrosis Foundation urges patients to use brand names only. Generic supplements are not as strictly formulated and are not guaranteed to have a consistent ratio of lipase, amylase and protease in each capsule.[3] A number of CF patients have reported extreme discomfort and major gastrointestinal problems as the result of taking generic enzymes.

The effectiveness of enzyme supplements has been called into question in the last few years. Because enzymes only work properly under very precise conditions, the FDA[4] is working hard to ensure that patients who receive enzyme supplements are indeed receiving the freshest, safest product. Clinical trials are underway and are schedule to conclude sometime in 2008.

Some important things to remember about enzymes:

-do not refrigerate them
-do not let them stay in the sun
-do not let the pharmacy substitute generic for name-brand
-do not skip doses

For more information, be sure to visit the links below:

Axcan Pharma (Maker of Ultrase)

CFF.org Enzyme Supplements

Solvay Pharmaceuticals (Creon)

Enzyme Stuff.com

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[1] Diabetes.org

[2] Enzyme Replacement Fact Sheet (pdf)

[3] New York Times article

[4] CFF info on enzymes