If you’ve been diagnosed with exocrine pancreatic insufficiency (EPI), you’ve probably received guidance about your eating habits and been prescribed pancreatic enzyme replacement therapy (PERT) to take with each meal. According to research, PERT can improve nutrient absorption and weight maintenance in people with EPI. It is also associated with an improved quality of life — and possibly a longer life.
But PERT isn’t perfect, and despite taking it, many people still have EPI symptoms. One study, published online in F1000 Research, showed that in people with EPI who were prescribed PERT, the dosage was frequently inadequate, and two-thirds reported ongoing symptoms of steatorrhea (excess fat in stools).
How to Maximize EPI Treatment
If you’re concerned that your treatment for EPI may not be working as it should, make sure you do the following.
- Take your prescribed treatment correctly. In some cases, EPI symptoms persist despite PERT, because people misunderstand the instructions about how to correctly time their doses. “If your EPI isn’t responding well to treatment, it’s possible that you’re not taking the enzymes appropriately,” says Rajesh Keswani, MD, a gastroenterologist and associate professor of medicine at Northwestern University Feinberg School of Medicine in Chicago. This occurs fairly commonly, so don’t feel discouraged if your doctor asks you to detail your current enzyme regimen and then tells you you’re not taking the enzymes correctly. The optimal time to take enzymes is often with meals, after the first bite of food, not only before or after. Ask your doctor to review the medication instructions with you.
- Take the correct enzyme dose. Know your correct PERT dosage and take it as prescribed. If EPI symptoms continue to bother you, Dr. Keswani says, your doctor may need to increase your dose. The F1000 Research study indicates that a large percentage of people treated with PERT who continue to experience steatorrhea are on enzyme doses that may be too low. If your doctor increases your enzyme dose, you should notice the effects almost immediately, Keswani says. Still, he adds, it’s good to wait a week after making any change to your treatment before evaluating how effective it is. If an increased dose doesn’t reduce your symptoms, it may be explained by one of two reasons: Either the enzymes aren’t working properly, or you have another condition besides EPI that’s contributing to your symptoms.
- Reduce excess stomach acid. The enzymes taken for EPI can sometimes be destroyed by stomach acid before they reach their intended target in the digestive system. If this occurs, your doctor may prescribe a proton pump inhibitor (PPI), a medication that reduces the production of gastric acid. Most of the enzyme pills for EPI are enteric coated, says Keswani, meaning they’re designed to protect against stomach acid, but in some people, this coating may not work as well. There are also some enzymes that are not enteric coated. In these cases, a PPI may help the enzymes work properly. It’s also possible that a PPI may be needed for a separate condition, Keswani says, such as gastroesophageal reflux disease, peptic ulcers, or gastritis.
- Manage gut bacteria. Many people with EPI have an imbalance of gut bacteria, but it’s unclear whether this is directly related to the condition. “It’s hard to say whether this is a true relationship or just two common things coexisting,” Keswani says. One way to remedy an imbalance of gut bacteria is to try probiotic supplements, which he says pose little risk. Because it’s unknown which probiotics may work better in some people than others, it may take a few tries before you notice any change in your symptoms. Ask your doctor whether probiotics might be beneficial for you and, if so, which supplements you should try.
- Treat conditions other than EPI. It’s common for EPI and another digestive condition to be present at the same time, Keswani says. When a person’s EPI treatment doesn’t seem to be working, doctors often look for celiac disease, irritable bowel syndrome, and infections as possible explanations. Tests can determine whether you have any other digestive conditions along with EPI. Work closely with your doctor to ensure you’re getting the treatment you need to reduce your symptoms and improve your digestive health.
Additional reporting by Erica Patino.
