What to Know About Pancreatic Enzyme Replacement Therapy (PERT)

The pancreas is an organ in the abdomen that is located behind the stomach. It makes enzymes and hormones that help in the digestion of food. If the pancreas doesn’t work well to create these substances, an individual might not be able to absorb all the nutrients from their food.

When the pancreas doesn’t produce enough of certain enzymes, it’s called exocrine pancreatic insufficiency (EPI). People with EPI may take medications called pancreatic enzyme replacement therapy (PERT) to get enough of the enzymes they need.

This article will discuss what pancreatic enzymes do, who may need pancreatic enzyme replacement therapy, and how to take these enzymes.

Person organizing pancreatic enzyme replacement therapy pills

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What Do Enzymes Do?

Enzymes that the pancreas creates include amylase, protease, and lipase. They leave the pancreas through ducts and travel to the small intestine to help with the digestion of food.

Without these enzymes, food isn’t digested properly. This can result in malabsorption. Malabsorption can cause unintended weight loss and many other complications, including fatigue and weakness.

The functions of these enzymes include:

  • Amylase: This enzyme breaks down carbohydrates from foods into sugars. Sugar is an energy source used by body systems. Without enough amylase produced by the pancreas, people may experience diarrhea from undigested carbohydrates.
  • Lipase: The function of lipase is to help break down fats in foods. When fats aren’t broken down, they pass through the digestive system and may lead to diarrhea. Stools that contain more fats (called steatorrhea) tend to be looser, stick to the sides of the toilet bowl, and may have a foul smell. 
  • Protease: This enzyme is important in the digestion of protein. It helps break proteins down into amino acids for the body to use. It also has roles in other areas of the body, such as supporting the immune system and blood clotting.

What Is Pancreatic Enzyme Replacement Therapy?

People who aren’t producing enough of the right mix of enzymes in the pancreas may be able to replace these enzymes with PERT. The medications prescribed will contain the enzymes amylase, lipase, and protease. They are approved by the Food and Drug Administration (FDA) to treat pancreatic insufficiency.

It’s important to have the right dosing to ensure that food is digested. The medication is usually taken before eating

Pancreatic Insufficiency Symptoms

The symptoms of EPI are similar to those caused by many other digestive conditions. Symptoms may start out mild and get worse over time as fewer and fewer enzymes are produced.

The symptoms of EPI include:

Talk to Your Healthcare Provider

The symptoms of EPI are much like those of other conditions, which may make diagnosis difficult or to take time. Working closely with a healthcare provider to look for the cause of symptoms is important to getting treatment.

FDA-Approved Brands

It’s important for people diagnosed with EPI to get the proper medications to treat the condition. There are many types of digestive enzymes that are sold over the counter. These are not the same as medications for EPI and may not contain the right mix of enzymes.

The generic name for these enzymes is pancrelipase. Some of the brand names include:

  • Creon
  • Palcaps
  • Pancreaze
  • Pangestyme EC
  • Panocaps
  • Pertzye 
  • Ultracaps
  • Ultresa
  • Viokace
  • Zenpep

Who Might Need It

There are several conditions associated with EPI. The most common cause is chronic pancreatitis, a long-term inflammation of the pancreas. Some of the causes include:

  • Celiac disease: A condition that causes an immune reaction to wheat protein (gluten)
  • Crohn’s disease: A condition that causes inflammation in the digestive tract
  • Cystic fibrosis: A genetic condition that causes damage to the lungs, pancreas, liver, and intestines
  • Diabetes mellitus: A condition that prevents the body from using the sugar from foods effectively
  • Gastric surgery: An operation on the intestines and stomach
  • Necrotizing acute pancreatitis: A condition in which part of the tissue of the pancreas dies
  • Pancreatic cancer: A type of cancer affecting the pancreas
  • Short bowel syndrome: A syndrome that develops when a significant amount of the intestines have been removed, which can affect nutrition
  • Surgery on the pancreas: Any operation that affects the pancreas
  • Zollinger–Ellison syndrome: A rare condition that causes tumors in the pancreas or small intestine

Proper Dosage

Dosing of medication for EPI is important. It might be challenging to work out the right dosage. There isn’t a consensus among experts about dosing across the different formulations. For children, the dose might be given based on body weight in kilograms.

One suggested dosage table is:

  • Infants: 2,000–4,000 units per 120 milliliters formula or breast milk
  • Child age under 4 years: 1,000 units per kilogram per meal, 500 units per kilogram per snack
  • Child age 4 years and older: 500 units per kilogram per meal, 250 units per kilogram per snack
  • Adult starting dose: 50,000 units per meal, 25,000 units per snack
  • Adult maximum dose: 150,000 units per meal, 70,000 units per snack

Getting the Right Dose

Always work with your healthcare provider to determine the right dose of enzymes for you. While learning how to manage EPI, asking questions and keeping track of symptoms will be a key part of PERT.

How to Take Pancreatic Enzymes

It may take time to determine the correct dosage for both adults and children. It might be recommended to start at a low dose and increase if and when needed. The enzymes need to be taken at the start of a meal or a snack.

The capsules should be swallowed whole. If they are chewed or crushed, they could irritate the mouth. It’s usually recommended that people swallow the capsules with a cold drink rather than a hot one.

However, for people who can’t swallow the pills (such as babies and children), ask a healthcare provider about opening the capsules and mixing them with food. Talk to a dietitian or healthcare provider about which foods to use when taking enzymes this way.

It’s recommended to finish a meal within 15 minutes after the enzymes are taken. If a meal takes longer to eat, such as 30 minutes, a healthcare provider may suggest taking half of the enzymes at the start of the meal and the other half about midway through.

Another strategy is to split the dosage up into thirds and take them at roughly one-third and two-thirds through the meal.

Taking Pancreatic Enzymes

Do
  • Take enzymes at the start of a meal or snack.

  • Split the dose if a meal will be longer than 30 minutes.

  • Swallow the capsules with a cold drink.

Don't
  • Open or crush the capsules unless instructed to by a healthcare provider.

  • Wait until during or after a meal or snack to take the enzymes.

  • Swallow the capsules with a hot drink.

Possible Side Effects

In general, there aren’t many side effects of PERT. Any difficulty using the medication usually comes when people are not taking enough enzymes. That would mean the symptoms of EPI aren’t being resolved and there might be a need for an increase in the dosage or a change to a different brand.

It’s possible to take too high of a dose of pancreatic enzymes. An overdose may cause a condition called fibrosing colonopathy. This has been seen in children who live with cystic fibrosis. Dosing is important, especially in children, in order to give the correct amount.

Diet and Pancreatic Enzyme Replacement Therapy

Bigger meals or those with more fat might need a larger dose of enzymes. People should talk to a healthcare provider about when they should adjust a dose based on what they’re eating and how to make those decisions. There may be an element of trial and error while understanding how to manage EPI and enzyme replacement.

Summary

PERT is an important part of managing EPI. Taking enzymes at the start of a meal can help in digesting food properly and avoiding symptoms such as malabsorption, diarrhea, and bloating.

A Word From Verywell

Having to take medications at every meal can be annoying at best and upsetting at worst. It will take time to learn the right amount of enzymes to take and when—which also might change over time.

However, when the dosage is right, it can help resolve the symptoms of EPI and avoid problems like losing weight or having diarrhea. Working with a mental health professional or social worker or join a support group might help in learning tips and getting help with learning to live with EPI.  

Frequently Asked Questions

  • How much does pancreatic enzyme replacement therapy cost?

    According to GoodRx, a 90-capsule prescription of 4,200 units each might cost between $110 and $140. Some manufacturers might have patient assistance programs. Contact the manufacturer of your drug or ask your healthcare provider or pharmacist about assistance programs. 

  • Are pancreatic enzymes safe to take long term?

    For people who have insufficiency, it’s important to take the enzymes for as long as needed. This treatment is considered both safe and effective.

  • Are pancreatic enzymes sold over the counter?

    No, pancreatic enzymes are not sold over the counter in drugstores or vitamin or health food stores. It’s important to get the right prescription enzymes from a healthcare provider to avoid the symptoms and potential complications of EPI. 

  • What other lifestyle changes can help manage EPI?

    Some of the other diet and lifestyle changes that are often recommended include quitting smoking; not drinking alcohol; eating smaller, more frequent meals; and eating an overall healthful diet. 

  • Is pancreatic enzyme replacement therapy needed forever?

    EPI is considered a lifelong condition. For this reason, it’s also likely that PERT will be needed throughout your lifetime. There are many lifelong considerations to take concerning EPI, including how it affects finances and the need for health insurance.

4 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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  2. AbbVie Inc. CREON [package insert].

  3. Borowitz D, Gelfond D, Maguiness K, Heubi JE, Ramsey B. Maximal daily dose of pancreatic enzyme replacement therapy in infants with cystic fibrosis: a reconsideration. J Cyst Fibros. 2013;12:784-785. doi:10.1016/j.jcf.2013.05.011. 

  4. Brennan GT, Saif MW. Pancreatic enzyme replacement therapy: A concise review. JOP. 2019;20:121-125.