Can Fodzyme exacerbate bile acid malabsorption?

Fodzyme May Worsen Bile Acid Malabsorption Symptoms

Fodzyme could potentially exacerbate bile acid malabsorption symptoms by increasing fat malabsorption, which is already a concern in severe bile acid malabsorption cases. 1

Mechanism of Concern

Bile acid malabsorption (BAM) occurs when bile acids are not properly reabsorbed in the terminal ileum, leading to excess bile acids entering the colon. This causes:

1. Osmotic diarrhea - Primary symptom of BAM 1
2. Fat malabsorption - Especially in severe cases 1

Fodzyme is an enzyme supplement designed to break down FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols). However, by increasing fat breakdown in the digestive tract, it could:

• Increase the amount of free fatty acids in the intestine
• Potentially worsen fat malabsorption in BAM patients
• Exacerbate diarrhea symptoms

Clinical Considerations

Severity-Based Risk Assessment

• Mild to Moderate BAM: Patients typically present with watery diarrhea but minimal fat malabsorption 2

  • These patients generally respond well to bile acid sequestrants like cholestyramine
  • Fodzyme might be less problematic in this group

• Severe BAM: Patients present with both diarrhea and steatorrhea 2

  • These patients already struggle with fat absorption
  • Adding Fodzyme could potentially worsen steatorrhea
  • In severe cases, cholestyramine itself may worsen steatorrhea 1

Specific Patient Populations at Higher Risk

1. Patients with ileal resection or Crohn's disease - Common causes of BAM 1
2. Patients with hyperoxaluria - Often have concurrent fat malabsorption 1
3. Patients with severe BAM - Already experiencing steatorrhea 2

Management Recommendations

If a patient with BAM is considering Fodzyme:

1. Assess BAM severity first:

   • Determine if the patient has steatorrhea or just watery diarrhea
   • Consider SeHCAT testing if available to quantify BAM severity 3

2. For patients with mild BAM:

   • Trial of Fodzyme might be reasonable with close monitoring
   • Continue bile acid sequestrants as first-line therapy 3

3. For patients with severe BAM or steatorrhea:

   • Avoid Fodzyme as it may worsen fat malabsorption
   • Focus on:
     • Low-fat diet supplemented with medium-chain triglycerides 2
     • Bile acid sequestrants (cholestyramine, colesevelam) 3
     • Additional symptom control with loperamide if needed 3

Important Caveats

• There are no direct studies specifically examining Fodzyme in BAM patients
• Individual responses may vary
• The theoretical concern is based on understanding of both BAM pathophysiology and Fodzyme's mechanism of action
• Patients with both BAM and IBS-D might face competing treatment goals

Monitoring

If a patient with BAM decides to try Fodzyme despite potential risks:

• Monitor for worsening diarrhea
• Watch for signs of increased steatorrhea (oily, floating stools)
• Track weight for signs of malabsorption
• Consider stopping Fodzyme if symptoms worsen

The primary treatment for BAM remains bile acid sequestrants, with cholestyramine as first-line therapy, showing response rates of 56-70% 3.