Who should take digestive enzymes?

From the Guidelines

Digestive enzymes are primarily recommended for individuals with specific digestive conditions that impair natural enzyme production or function, such as pancreatic insufficiency, and should be taken under the guidance of a healthcare professional. People with pancreatic insufficiency, such as those with chronic pancreatitis, cystic fibrosis, or who have had pancreatic surgery, should take prescription-strength pancreatic enzyme replacement therapy (like Creon, Zenpep, or Pancreaze) with meals and snacks, as recommended by the AGA clinical practice update on the epidemiology, evaluation, and management of exocrine pancreatic insufficiency 1. Typical dosing ranges from 25,000 to 40,000 lipase units per meal, adjusted based on symptoms and fat malabsorption, with the initial treatment of at least 40,000 USP units of lipase during each meal in adults and one-half of that with snacks, as suggested by the study 1. Some people with inflammatory bowel disease, celiac disease, or age-related enzyme decline may also benefit from over-the-counter digestive enzyme supplements, which should be taken just before meals to maximize effectiveness.

Key Considerations for Digestive Enzyme Use

• The use of pancreatic enzyme replacement therapy (PERT) is vital to maintain adequate nutritional status in individuals with pancreatic insufficiency, as emphasized by the ESPEN-ESPghan-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis 1.
• PERT should be taken during the meal to maximize mixing and digestion of nutrients, with a focus on lipase dose and meal fat content, as recommended by the AGA clinical practice update 1.
• The efficacy of PERT is well established, and its use can improve outcomes in patients with chronic pancreatitis and cystic fibrosis, as noted in the ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1.
• Routine supplementation and monitoring of fat-soluble vitamin levels are appropriate, along with dietary modifications that include a low-moderate fat diet with frequent smaller meals and avoiding very-low-fat diets, as suggested by the AGA clinical practice update 1.

Important Factors in Digestive Enzyme Therapy

• The choice of pancreatic enzyme preparation, including enteric-coated microspheres or tablets, can affect the efficacy of treatment, with enteric-coated microspheres potentially being more effective, as noted in the ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1.
• The addition of proton pump inhibitors may improve the effectiveness of PERT, as suggested by the ESPEN-ESPghan-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis 1.
• Monitoring of growth and/or nutritional status at regular intervals is recommended to determine the adequacy of treatment, as emphasized by the ESPEN-ESPghan-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis 1.

From the Research

Individuals Who May Benefit from Digestive Enzymes

• People with lactose intolerance, as they may benefit from lactase (β-galactosidase) supplementation 2, 3
• Individuals with cystic fibrosis, who may require pancreatic enzyme replacement therapy 2, 4
• Patients with exocrine pancreatic insufficiency, including those with chronic pancreatitis, severe acute necrotizing pancreatitis, pancreatic cancer, and gastrointestinal and pancreatic surgical resections 4
• Those with celiac disease, who may experience exocrine pancreatic insufficiency and benefit from pancreatic enzyme supplementation 5
• Individuals with malabsorption and other digestive disorders, who may benefit from enzyme supplementation, including plant-based and microbe-derived enzymes 3

Specific Conditions and Enzyme Supplementation

• Pancreatic exocrine insufficiency: requires oral administration of pancreatic enzymes to provide sufficient active lipase in the duodenal lumen 4
• Celiac disease: patients may require long-term enzyme supplementation, but some may be able to discontinue supplementation as symptoms improve 5
• Lactose intolerance: lactase (β-galactosidase) supplementation can help break down lactose and alleviate symptoms 2, 3

Types of Enzyme Supplementation

• Animal-derived enzymes: established standard of care, but may have limitations 2
• Plant-based enzymes: offer a promising alternative, with examples including bromelain from pineapple 3
• Microbe-derived enzymes: show promise in the treatment of digestive disorders, with benefits including a broader pH range and lower dosage concentration 3