Exocrine pancreatic insufficiency (EPI) is a condition in which the pancreas doesn’t make enough enzymes to properly break down food. Causes of this condition can include:

  • chronic pancreatitis
  • pancreatic cancer
  • cystic fibrosis
  • celiac disease
  • pancreatic surgery

The pancreas is a digestive organ located behind the stomach. It creates pancreatic juices, also called enzymes, which break down fats, proteins, and carbohydrates. The pancreas plays a big role in converting food into a fuel source for the body.

EPI affects how your body digests food and makes it harder for you to get the nutrients you need. Symptoms can include:

  • stomach pain
  • gas
  • bloating
  • constipation
  • diarrhea
  • unexplained weight loss

EPI can lead to malnutrition, but treatments can help your body receive adequate nutrients to function properly. Treatments can include a high calorie diet, vitamin supplementation, and pancreatic enzyme replacement therapy (PERT).

PERT can help treat EPI symptoms by replacing the enzymes that your pancreas no longer makes. Through PERT, you’ll receive these digestive enzymes in the form of a capsule.

The capsule enables your body to break down the proteins, fats, and carbohydrates in the foods you eat. Besides relieving the symptoms of indigestion, it can also reduce the likelihood of complications like malnutrition.

PERT capsules contain three types of digestive enzymes, which your pancreas would naturally make and release:

  • proteases (for digesting protein)
  • lipases (for digesting fats)
  • amylases (for digesting carbohydrates)

PERT capsules come in different units of digestive enzymes. Talk with your doctor about the specific number of units per capsule you should take.

This medication differs from other medications in that you’re not prescribed a set dose per day. The general guideline is to take it right before eating, but the amount you take varies depending on your weight and how much you’re eating.

For example, you might take 50,000 units or 75,000 units before dinner — the equivalent of two or three capsules. But if you’re having a snack, you might only need one or two capsules before eating — the equivalent of 25,000 or 50,000 units.

The amount you’ll need also depends on your level of insufficiency. You’ll likely start at a lower dose (maybe 20,000 units and 40,000 units for snacks and meals, respectively).

Your doctor or dietitian can monitor your symptoms and then increase the dose as necessary. Keeping a food journal and recording your symptoms can help determine whether you need a higher amount of enzymes.

The benefits of PERT include better digestion and the reduction of EPI symptoms, such as diarrhea, constipation, and abdominal pain. But the treatment doesn’t always come without risks.

Just as you might experience symptoms from insufficient enzymes, taking too much of the enzymes can also cause side effects like diarrhea and stomach pain. If symptoms don’t improve after starting therapy, speak with your doctor or dietitian.

An allergic reaction to this medication is rare. Seek immediate medical care if you experience symptoms of an allergic reaction, such as:

  • tightness in the throat
  • hives
  • difficulty breathing

If you’re allergic to pork or don’t eat pork for religious reasons, be mindful that pigs are used in the preparation of these enzymes. Currently, there isn’t an alternative to using pigs.

Stomach acid can destroy enzymes before they reach their target, so having too much of it — such as in cases of acid reflux or GERD — can affect how well an enzyme works.

If you’re not responding to treatment, your doctor may prescribe a proton pump inhibitor (PPI), which can help reduce the production of stomach acid and are used to treat conditions such as acid reflux and GERD.

In addition to taking the correct unit of enzymes before meals and snacks, here are a few more tips to improve how your body responds to PERT:

  • Take capsules with a cold drink. Mixing the capsule with a hot liquid can reduce its effectiveness.
  • Take the enzymes at the beginning of meals, with the first bites of food. If you wait until after the meal, the enzymes may not work properly.
  • If you’re taking two or three capsules with your meal, you can take one capsule at the beginning of the meal, and the other capsules at separate points through the meal.
  • You should take your PERT medication if you are having a milk-based beverage. The exception is when a drink only contains a small amount of milk (such as a splash of milk in coffee or tea).
  • If you have trouble swallowing the capsules, you can open the capsule and mix the granules with cold, soft acidic foods such as applesauce or gelatin. Granules should be swallowed whole and not chewed to prevent mouth sores.
  • You won’t need to take enzymes when eating fresh or dried fruit, or when nibbling on a small amount of vegetables.
  • Don’t store enzymes in hot locations, such as inside your car. This can reduce their effectiveness.
  • Don’t forget to take enzymes before drinking nutritional supplement drinks.

The pancreas is an important organ, as it helps your body digest carbohydrates, fats, and protein. EPI can reduce your body’s ability to break down these foods, but PERT can assist digestion. The treatment not only relieves bothersome symptoms but can also reduce the risk of malnutrition.

Speak with your doctor if you develop symptoms of EPI or if your current treatment for EPI isn’t working.