Is Now Pancreatin Sufficient PERT for Chronic Pancreatitis?
No, Now Pancreatin is not sufficient as pancreatic enzyme replacement therapy (PERT) for chronic pancreatitis—the 170mg pancreatin dose is substantially below guideline-recommended therapeutic levels and should not be relied upon as sole therapy for documented pancreatic exocrine insufficiency (PEI). 1
Why Now Pancreatin Falls Short
The lipase content in Now Pancreatin is inadequate for treating clinically significant PEI. Patients with confirmed PEI require properly dosed enteric-coated pancreatic enzyme preparations delivering 40,000-80,000 PhU (pharmacopoeial units) lipase per meal, with a minimum of 20,000-50,000 PhU with main meals and half that dose with snacks. 1, 2 Over-the-counter or low-dose enzyme products lack standardized potency and should not substitute for FDA-approved prescription PERT formulations. 1
The Clinical Consequences of Inadequate Treatment
Undertreatment with insufficient PERT doses leads to serious morbidity. A Dutch study found that 70% of chronic pancreatitis patients remained undertreated, still experiencing steatorrhea-related weight loss despite being on some form of enzyme therapy. 3 The consequences of inadequate PERT include:
- Persistent steatorrhea and malabsorption 3
- Progressive undernutrition and weight loss 3
- Fat-soluble vitamin deficiencies (A, D, E, K) 2, 4
- Osteoporosis and atraumatic fractures 3
- Continued adverse gastrointestinal symptoms 3
Even mild to moderate chronic pancreatitis causes clinically significant fat malabsorption, contrary to outdated narratives that the pancreas must be virtually destroyed before malabsorption occurs. 3 Delays in prescribing adequate PERT have direct negative impacts on nutritional status and quality of life. 3
What Constitutes Adequate PERT
Prescription-strength enteric-coated PERT is the standard of care. The preferred formulation consists of pH-sensitive, enteric-coated microspheres (ideally mini-microspheres 1.0-1.2 mm in diameter) that protect enzymes from gastric acidity and allow disintegration at pH >5.5 in the duodenum. 2 These formulations have higher therapeutic efficacy compared to larger microspheres or non-coated preparations. 2, 5
Dosing must be adequate to normalize digestion, not just reduce symptoms. Meta-analysis demonstrates that PERT improves coefficient of fat absorption from 63.1±15.0% at baseline to 83.7±6.0% with treatment (p<0.00001), with high-dose and enteric-coated enzymes showing trends toward greater effectiveness. 5
When Now Pancreatin Might Be Appropriate
This low-dose combination is only suitable for very limited clinical scenarios:
- Mild dyspepsia with bloating in patients without documented PEI 1
- Adjunctive symptomatic relief in patients already receiving adequate-dose prescription PERT 1
- Mild digestive complaints where malabsorption has been definitively ruled out 1
If steatorrhea, weight loss, or nutritional deficiencies are present, immediately initiate prescription-strength enteric-coated PERT at guideline-recommended doses. 1
Optimizing PERT Effectiveness
When adequate-dose PERT fails to control symptoms, consider these factors:
- Acidic intestinal pH: Add proton pump inhibitors or H2-antagonists to prevent gastric acid from denaturing pancreatic enzymes, enhancing enzyme efficacy and improving fat absorption 1, 4, 6
- Small intestinal bacterial overgrowth (SIBO): Occurs in up to 14-92% of PEI patients and may require several courses of antibiotics 3
- Timing: Enzymes should be consumed during meals, not before or after, to ensure simultaneous delivery with nutrients 2, 5
- Dose titration: May need to increase lipase units if response is suboptimal 3
Critical Pitfalls to Avoid
Do not assume that over-the-counter pancreatic enzyme products are equivalent to prescription PERT. The standardization, potency, and bioavailability differ substantially. 1
Do not wait for severe disease before initiating adequate PERT. Fat malabsorption occurs even in mild or moderate chronic pancreatitis, and early identification and treatment is key to preventing nutritional complications. 3
Monitor treatment adherence and adequacy. A cross-sectional study of expert centers found that 25% of PEI patients were not taking enzymes at all, and 20% were undertreated with insufficient doses—both patient factors (smoking, alcohol abuse) and center differences influence treatment adherence. 7