Pancreatic enzyme replacement therapy (PERT) is the main treatment for exocrine pancreatic insufficiency (EPI). PERT replaces the digestive enzymes that the pancreas does not produce or release.

EPI occurs when the pancreas does not make enough of the digestive enzymes that the body needs to break down food and absorb nutrients.

People take PERT medications with food, and these drugs assist in digestion and nutrient absorption.

Learn more about PERT, including why it is needed and how to make the most of the treatment, here.

PERT involves taking medications to replace the digestive enzymes that the pancreas normally produces. PERT medications contain pancrelipase, which is a mix of the digestive enzymes lipase, protease, and amylase. These enzymes assist in the process of digestion and help break down fat, protein, and carbohydrates in food.

PERT medications come in the form of capsules. People must take PERT medications orally at each meal and snack.

In the United States, PERT comes in two forms: enteric-coated and non-enteric-coated.

The Food and Drug Administration (FDA) has approved five enteric-coated formulations:

  • Creon
  • Zenpep
  • Pancreaze
  • Pertzye
  • Ultresa

The enteric coating stops gastric acid from breaking down the capsule. The coating dissolves once it reaches the duodenum.

The FDA has also approved one non-enteric-coated formulation: Viokace.

Generally, the formulations that have an enteric coating are preferred. However, factors such as insurance coverage or cost may influence which formulation a person takes.

PERT medications derive from glands located in the pancreases of pigs. People who do not ingest pork products due to religious reasons may be granted an exemption from religious leaders to use these medications.

To understand PERT, it is important first to have an understanding of the role of the pancreas in digestion and EPI.

The role of the pancreas

The pancreas serves an important function in the digestion of food. It produces chemicals called pancreatic enzymes that help break down carbohydrates, fat, and protein into smaller parts. This allows the body to absorb the nutrients it needs to function.

The pancreatic enzymes involved in this process are:

  • lipase, which breaks down fat into fatty acids
  • protease, which breaks down protein into amino acids and peptides
  • amylase, which breaks down carbohydrates into simple sugars

The digestion process begins in the mouth as soon as a person consumes food. Chewing and saliva break this food down. Swallowing moves the food down the esophagus and into the stomach. In the stomach, the food is further broken down before traveling to the duodenum in the small intestine.

The duodenum is connected to the pancreas by a tube known as the pancreatic duct. The pancreas produces a juice-like substance containing pancreatic enzymes that travels through this tube into the duodenum.

In the duodenum, food mixes with pancreatic enzymes and bile from the gallbladder. Nutrients are absorbed into the bloodstream. Waste products are moved to the large intestine.


EPI occurs when the pancreas does not produce or release enough pancreatic enzymes to aid digestion. This can happen if the pancreas is damaged or if the pancreatic duct is blocked. Sometimes, both of these things can happen.

If the pancreas does not produce or deliver enough enzymes to break down food, people cannot digest nutrients properly. This is known as malabsorption.

Symptoms of EPI may include:

  • fatty stools
  • bloating
  • abdominal pain
  • flatulence
  • diarrhea
  • unexplained weight loss

Because people with EPI are not able to absorb nutrients properly, they are at risk of malnutrition. Symptoms of malnutrition may include:

  • fatigue
  • bruising
  • problems with wound healing
  • bone problems
  • muscle weakness


PERT is the main form of treatment for EPI. It involves taking capsules that contain replacement enzymes to make up for the lack of enzymes from the pancreas.

People with EPI need to take PERT medications any time they eat food. These drugs release the necessary enzymes into the duodenum. This allows the body to digest food and nutrients properly.

People with EPI should take their PERT medication at each meal and snack. They should also take their PERT medication if they consume milk-based drinks.

The dosage of PERT medications will vary based on the person. It will depend on a number of factors, including the person’s body weight, their level of pancreatic function, and the size and fat content of their meals.

A person’s doctor will be able to advise what dosage is best for them. They may suggest beginning with a lower dosage and gradually increasing this over time.

People should take PERT capsules with the first mouthful of food or milk-based drink they consume. This allows the enzymes to mix with the food. If a person takes PERT capsules too early before eating, they will not come into contact with the food.

It is important to swallow the capsules whole and to take them with a cold drink. Hot beverages can render the enzymes less effective, as high temperatures can damage them.

For a large meal or a meal lasting for longer than 30 minutes, people may need to take half of the capsules at the start of the meal and the rest spread throughout the meal.

People may need to take more PERT capsules for large or high fat meals than for meals that are small and low in fat. A person’s doctor can provide instructions on how to vary PERT medication doses based on meals.

PERT has many benefits and also some risks.

With correct use, PERT can provide a variety of benefits, including:

  • a reduction in fatty stools
  • a reduction in abdominal pain
  • a reduction in flatulence
  • improved nutrient absorption
  • an increase in body weight
  • better absorption of fat, carbohydrates, and protein
  • an improvement in overall quality of life

However, PERT does carry some risks. Possible side effects of PERT include:

  • nausea
  • discomfort in the abdomen
  • constipation
  • diarrhea

In the majority of cases, these symptoms will resolve with time.

To make the most of PERT, people with EPI should closely follow any instructions their doctor gives them. If in doubt, they should ask questions.

There are a number of steps that people can take to help make PERT treatment more effective. These include:

  • avoiding taking the medication on an empty stomach
  • taking capsules with the first mouthful of food
  • swallowing capsules with a cold drink
  • spacing out the medications if eating a larger meal, unless their doctor has given other instructions
  • eating smaller meals more frequently
  • eating a nutritious diet that contains vegetables, fruits, healthy protein, and whole grains
  • working with a doctor or dietitian to determine how much fat to eat
  • storing PERT capsules at room temperature
  • noting how their body reacts to PERT and talking with a doctor about making adjustments, if needed
  • speaking with a doctor if they experience any side effects

PERT is a medical treatment for EPI.

PERT involves taking oral medications that replace the enzymes that the pancreas does not make or release. This lack of enzymes can occur due to damage to the pancreas or a blockage to the pancreatic duct.

When a person takes the capsules with food, PERT helps with digestion and nutrient absorption. This can improve symptoms associated with EPI and enhance quality of life.