Pancreatic

Enzyme
Replacement
Therapy
Pancreatic Disorders
Patient Guide

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 What is the pancreas?
The pancreas is a gland that lies underneath the stomach.
gland: It produces digestive enzymes and insulin. Both of these are
an organ that essential for you to gain nutrition from the food you eat.
releases chemicals
Digestive enzymes help you break down food so that it can be
for use in the body
absorbed from your gut into your bloodstream and used by
your body. Without these enzymes, food will pass through your
digestive system without being broken down and absorbed
into your body.

enzyme: The pancreas produces three main types of enzymes to break

a substance down different parts of your food:
produced
■■ Proteases (to break down proteins)
by the body which
brings about a ■■ Amylase (to break down starchy carbohydrate)
specific reaction ■■ Lipase (to break down fat)
The pancreas is the main gland in the body that produces
the enzyme lipase.

Liver

Stomach

Bile duct
Pancreas
Duodenum

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 What is malabsorption?
When your pancreas is diseased (i.e. in pancreatic cancer)
or inflamed (i.e. in pancreatitis), or if some of your pancreas has
been removed or affected by surgery, it may not be producing
enough enzymes. Occasionally this may occur after surgery
to your stomach or duodenum. Without enough of these
enzymes, you may find that some of the food and fluids you abdomen:
take are not absorbed very well. This is called malabsorption. part of the body
containing the
digestive organs
How do I know if I am suffering bounded by the
with malabsorption? diaphragm
The colour of your stools may tell you if you are not absorbing
and pelvis
your food. If fat is present in your stools, they may look pale
or yellow. They may float, and may be difficult to flush away.
You may see orange fat globules on them, and they will usually
osteoporosis:
be loose and frequent. You may also lose weight. If you have
a condition which
reduced the amount of fat you eat you may not have these
causes a thinning
symptoms. If this is the case, it is recommended that you
of the bones
discuss how you have changed your diet with your doctor
or dietitian.
If you are not absorbing starchy carbohydrates (i.e. potatoes,
pasta, bread, cereal) this can cause bloating, wind and
abdominal pain. Weaker muscles and weight loss may be the
only signs of malabsorption.
It is more difficult to tell whether you are absorbing some
of the vitamins and minerals. Blood tests should help identify
any deficiencies you may have. It may be necessary to take
dietary supplements to improve your stores of these vitamins
and minerals.
Long-term deficiencies can cause conditions such as
osteoporosis and night blindness. It is therefore important to
monitor your vitamin and mineral levels and take supplements
if necessary.
Erratic or difficult to control blood sugar levels can be a sign
of malabsorption.

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 What is pancreatic enzyme
replacement therapy?
To help your body absorb food you can take the enzymes you
need in the form of a capsule. This is called pancreatic enzyme
replacement therapy. You will usually be prescribed one of the
following medications:
■■ Creon®
■■ Nutrizym®
■■ Pancrease®
■■ Pancrex®
Pancreatic enzyme replacement therapy comes in different
forms and strengths. They are usually taken as capsules, and
each has a different number or letter following their name
to indicate the dose strength. Some also come in powder
or granule form. All preparations contain a mixture of all the
pancreatic enzymes: lipase; amylase and protease.
Pancreatic enzyme supplements are made from pork products.
There is currently no alternative. Please discuss this with your
dietitian or doctor if you have any concerns.

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 How do I take pancreatic enzymes?
The enzymes inside the capsules replace those that your
pancreas is unable to produce.
To work effectively, these enzymes need to be taken each time
you eat, including meals, snacks and milky drinks. Take them
just before you begin eating or with the first few mouthfuls of
food as they need to be taken with the food/milky drink to work.
If you take more than one capsule you should space them
out throughout your meals.

If you are having a large meal with more than two courses,
or one lasting more than half an hour, you may need to take
additional enzymes with each course.
It is important that you swallow your capsules with a cold
drink. Swallowing them with a hot drink (like tea or coffee) may
damage them and make them less effective.
Pancreatic enzymes can be damaged at high temperatures.
You will need to read the information leaflet for your medicine
for details about the maximum storage temperature. Do not
keep the capsules in warm places such as window sills, near
radiators, in the car or in direct sunlight. They may also be
affected by your body heat if they are kept in trouser pockets.

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 How many enzymes do I take?
You will need to take enough enzymes to enable your body
to digest and absorb food adequately. Your initial dose will be
decided by your doctor or healthcare professional. This dose
may be gradually increased until your symptoms are controlled.
You may need more enzymes to help you digest very fatty foods
(such as fried food, takeaways and foods containing lots
of cheese, chocolate and pastry).
Your dietitian will explain how you can tell how many enzyme
capsules are needed with each meal or snack. This includes
even small snacks and any drink which is at least half milk.
It is important that you take your enzymes with all your meals
and snacks. Without them, symptoms of malabsorption
may recur along with weight-loss and vitamin and mineral
deficiencies. Sometimes you can experience deficiencies
without other symptoms, so it is important you don’t stop
taking your enzymes even if you feel you no longer need them.
Other medications such as painkillers, can mask some of the
symptoms of malabsorption, making it difficult to adjust your
enzyme dose. Speak to your doctor or dietitian if you experience
symptoms like constipation.
Reducing your pancreatic enzyme dose may seem to help with
constipation, but usually does so by causing malabsorption.
This will cause malnutrition. It is better to take a laxative or take
other steps to treat constipation in this instance.

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 What is my dose?
The dose you need is individual to you. It depends on your condition and the types
of foods you eat. You may find that your starting dose is increased until your
symptoms are controlled.
Your dietitian or doctor will help you adjust the dose of enzymes to ensure
your symptoms are under control. It is important that this is done gradually.

Your starting dose is:

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 When not to take enzyme supplements
■■ If you miss a meal. Do not take enzymes on an
empty stomach
■■ With drinks that are less than half milk such as tea,
non-milky coffee, fruit squashes and fizzy drinks
■■ If you are eating small quantities of any of the following:
– Fruit (other than avocado or pear)
– Vegetables (other than potatoes, beans and pulses)
– Dried fruit
– Sugary sweets: jelly babies, wine gums, dolly mixtures,
marshmallows, fruit pastilles, chewing gum, and mints
■■ If you take a very small quantity of another food,
for example:
– An individual chocolate
– A small plain biscuit

Some people can manage larger quantities of low fat foods

without enzymes. This can be assessed by your dietitian, doctor
or nurse specialist once you have established the dose that
works best for you.
It is important that you take your enzymes with all other meals
and snacks.

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 What if I can’t swallow them?
You can open the capsules and mix the granules (without
crushing) with an acidic fruit puree, such as apple sauce. You
will need to swallow the mixture straight away, without chewing.

Rinse your mouth around with water and swallow to ensure

you take all the enzymes and they don’t get stuck in your teeth,
gums or dentures.
Alternatively you can ask for a lower dose enzyme capsule.
These are smaller than the higher dose enzyme capsules and
you will need to take more of them in order to receive your
required dose.

Granulated enzymes
If you have been prescribed granulated enzymes then there are
a few things that you need to do differently. Granulated enzymes
can cause mouth ulcers if they get stuck between your teeth
and gums. To reduce this risk, follow these four steps:
1. Mix your prescribed dose with one spoonful of apple sauce
or fruit purée
2. Do not chew
3. Swallow immediately
4. Take a cold drink to wash the enzymes clear of your mouth

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 What happens if I take more than
I am prescribed?
Read the instruction leaflet carefully. This is not usually
dangerous. Drink plenty of fluids and continue taking your
enzymes with the next meal as usual. If you feel unwell,
contact your doctor.

Are there any side effects?

Since some people experience side effects from enzyme
replacement therapy, it is important to read the medicine
information leaflet, or speak to your doctor or pharmacist if you
have any concerns. The most frequent side effects are nausea,
vomiting and abdominal discomfort. These usually settle with
time, or by changing the brand of enzymes.
If the enzymes move through you too fast you may experience
irritation of the anus. This usually occurs if you have severe
diarrhoea before you start taking enzymes. Using antidiarrhoeal
medication can help reduce diarrhoea. These symptoms are
usually temporary and clear when your diarrhoea stops. If you
get severe diarrhoea, let your doctor, nurse or dietitian know.
If you experience discomfort or burning around your anus (this
is usually worse after a bowel motion) let your doctor know.
Make sure you keep the area clean by washing gently after
every bowel motion. This will help to prevent infection.
After washing and drying the area, apply a barrier cream which
can be purchased from the pharmacy.

Do I need to have a low fat diet?

It is not usually necessary to follow a low fat diet, though it’s
useful to identify high fat foods in your diet so you can take
more enzymes with them. But don’t feel you need to avoid
high fat foods.
Higher fat foods may be beneficial for those who have lost a lot
of weight, or are below an ideal weight. Your dietitian can
provide you with more information on this.

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 What about other supplements?
Sometimes it is necessary to take some high energy nutritional
supplements to stabilise your weight or help gain weight. It is
important that these are balanced with your enzyme capsules.
Your dietitian will offer advice.

Vitamins and minerals

People taking pancreatic enzymes often need additional
vitamins and minerals to help prevent long-term deficiencies, osteopenia:
such as osteopenia and osteoporosis. a slight thinning of
the bones, less
If you need a vitamin and mineral supplement, please read severe than
the information leaflet supplied. These supplements should
osteoporosis
be taken with a meal to improve absorption.
However, if you are taking a calcium supplement this must
be taken outside meal times.

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 Summary Reporting of side effects
If you get any side effects,
■■ Lifelong pancreatic enzyme supplementation is important talk to your doctor,
for your nutrition and long-term health pharmacist, dietitian or
nurse. This includes any
■■ Dose and frequency varies between individuals possible side effects not
listed on the package leaflet.
■■ Your dietitian and doctor are there to help with any queries You can also report side
or concerns effects directly via the
Yellow Card Scheme at
www.mhra.gov.uk/yellowcard.
For more information contact your dietitian, By reporting side effects
doctor or clinical nurse specialist: you can help provide more
information on the safety
of these medicines.

This leaflet was written by the healthcare professionals listed below and produced by Mylan:
Mary Phillips, Dept of Nutrition and Dietetics and Regional Hepato-Pancreatico-Biliary Unit,
The Royal Surrey County Hospital NHS Foundation Trust.
Sinéad Duggan, Dept of Nutrition and Dietetics and Centre for Pancreatico-Biliary Diseases, Tallaght Hospital, Dublin.
Laura McGeeney, Dept of Nutrition and Dietetics, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust.
Jeremy J French, Hon Secretary, Pancreatic Society of Great Britain and Ireland, Consultant in Transplantation and Hepatobiliary Surgery,
Freeman Hospital. Members of the Nutrition Interest Group, Pancreatic Society of Great Britain and Ireland.

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