Pancreatic enzyme replacement therapy (PERT) can help improve or resolve symptoms of exocrine pancreatic insufficiency (EPI). If symptoms persist, a person may consider speaking with a doctor about adjusting their treatment.

Exocrine pancreatic insufficiency (EPI) occurs when the pancreas is unable to make enough digestive enzymes. These enzymes are needed to properly digest food and allow the body to absorb nutrients.

Pancreatic enzyme replacement therapy (PERT) is an oral treatment that replaces the enzymes the pancreas does not produce.

In many people, symptoms will improve or resolve with PERT. If symptoms persist despite taking PERT, it may be a sign that the dosage needs to be adjusted or that there are other issues present.

Learn more about PERT, how to use it effectively, and what to do if symptoms persist.

When working properly, the pancreas produces enzymes that help break down foods in the digestive system. The body then absorbs important nutrients from these foods.

The enzymes produced by the pancreas include:

  • amylase, which helps digest carbohydrates
  • protease, which helps break down proteins
  • lipase, which helps digest fats

In people who have EPI, the pancreas does not make enough of these enzymes that are needed to break down foods and allow the nutrients to be absorbed by the body.

PERT involves taking an oral supplement that contains amylase, protease, and lipase. This helps replace the enzymes the pancreas is unable to produce.

The dosage of PERT will vary from person to person. A doctor will typically advise the correct dosage to take. This may involve a lower dose initially before building up until all symptoms are managed.

PERT usually comes in capsule form. Depending on factors such as a person’s PERT dosage, the size of a meal, and how long it takes to eat it, a person may need to take several PERT capsules over the course of a meal.

The first PERT capsule is taken with the first mouthful of food and the remaining capsules are then spread throughout the meal.

The capsules need to be taken:

  • when eating meals
  • when eating snacks
  • when drinking milk-based beverages

If a person with EPI consumes a large meal that continues for more than 30 minutes, or involves more than two courses, enzymes must be taken with each course.

PERT may help improve EPI symptoms or resolve them entirely. For example, studies have found that at least 30,000 IU of lipase taken at each meal should eliminate steatorrhea, or fatty stools.

If a person continues to experience EPI symptoms while taking PERT, it may be a sign the treatment is not working as well as it should.

Symptoms to look out for include:

  • unexplained weight loss
  • pain in the abdomen
  • gas
  • bloating
  • greasy or oily stools
  • foul-smelling stools
  • diarrhea

If an individual continues to experience these symptoms, they should consider speaking with a doctor about adjusting their treatment plan.

There are several reasons PERT may not be working, such as:

  • A higher dosage is needed.
  • A person is not taking PERT as prescribed.
  • The PERT capsules are stored at hot temperatures, which can make them less effective.
  • Other underlying health conditions are impacting treatment.

If a person is taking PERT but their symptoms are not improving, they may consider speaking with a doctor.

In some cases, experiencing symptoms of EPI while on PERT can be an indication more enzymes are needed. Everyone who takes PERT will have a unique dosage.

Many people will need to increase the amount of enzymes from their first dosage. A doctor can help with this, as well as help review the dosage regularly.

Sometimes, a doctor may recommend changing the type of enzymes taken to see if symptoms improve.

They may also prescribe proton pump inhibitors (PPIs), which can help make enzymes more effective. PPIs work by stopping the stomach from producing too much acid, which can impact how enzymes work in the body.

If symptoms such as diarrhea persist even after increasing the PERT dosage, a doctor may order tests to rule out other causes.

In some cases, symptoms can be due to other causes that impact the digestive system. These include:

  • antibiotic use
  • opioid use
  • chemotherapy

In addition to speaking with a doctor about their PERT dosage, there are several things people can do to maximize their EPI treatment.

In order to get the most benefit of PERT for EPI, it is important to closely follow the directions provided by a doctor.

Every person taking PERT will have different dosage instructions, based on individual circumstances.

People may need to vary their PERT dosage or the amount of capsules they take based on the size and fat content of their meals. In some cases, a doctor may also recommend spreading the dosage out across a meal.

Other tips to ensure PERT is most effective include:

  • Do not take PERT on an empty stomach.
  • Do not swallow PERT with a hot drink (enzymes can be damaged at hot temperatures).
  • Avoid crushing or chewing PERT capsules, they must be taken whole.
  • Store PERT capsules at room temperature.
  • Eat small meals more regularly.
  • Discuss how much fat to consume with a doctor or a registered dietitian, if a person has access to one.
  • Observe how the body responds to PERT, and speak with a doctor so adjustments can be made if needed.

Over-the-counter remedies

The main treatment for EPI is PERT, which requires a prescription.

In some cases, an over-the-counter proton pump inhibitor (PPI) may also be recommended. These include:

  • lansoprazole (Prevacid)
  • omeprazole (Prilosec)
  • esomeprazole (Nexium)

People with EPI may have difficulty absorbing nutrients from food. In some cases, a doctor may recommend taking a vitamin or mineral supplement to help prevent nutrient deficiencies. These may include:

  • vitamin A
  • vitamin D
  • vitamin E
  • vitamin K

Can the pancreas heal itself from EPI?

EPI is not reversible, but treatment and certain lifestyle changes can help people manage their symptoms.

Any disease that can impact the tissue in the pancreas can cause EPI. These include conditions such as:

  • cystic fibrosis
  • pancreatic cancer
  • acute or chronic pancreatitis

If the pancreas is damaged, it may not produce enough enzymes, which can result in EPI.

In cases of chronic pancreatitis, the damage to the pancreas is permanent.

An acute case of pancreatitis that causes death to pancreatic tissue can also not be reversed.

Cystic fibrosis is an incurable disease, and can damage the pancreas.

How long can people go without treatment for EPI?

EPI can sometimes be difficult to recognize. But once identified, treatment is recommended. Without treatment, people with EPI risk serious complications and even death. Those with EPI can have a good quality of life with proper treatment.

Can people die from untreated EPI?

Untreated EPI can be serious and can result in death. It can also cause morbidity due to malnutrition, poor quality of life, and serious complications.

PERT is a treatment for EPI that is taken orally. If effective, it can help reduce or completely resolve symptoms of EPI.

In some people, symptoms may persist even when taking PERT. This can be a sign the treatment may not be working effectively. This can indicate the dosage needs to be adjusted, or that a different type of enzyme should be taken.

In some cases, symptoms may also persist for other reasons, such as antibiotic use.

If symptoms persist whilst on PERT, it is a good idea to discuss this with a doctor. They will be able to assess if a dosage needs to be changed, if a proton pump inhibitor is needed, or if other factors are contributing to symptoms.