Alternative Digestive Enzymes

Graphic model of an enzyme.

The majority of us with cystic fibrosis or pancreatic insufficiency require pancreatic enzyme supplementation in order to digest our food. We need this because our pancreases may not produce enough pancreatic enzymes on our own due to a genetic mutation or other pancreatic malfunction. When this happens, the most common conventional intervention is prescription-strength digestive enzymes which are enteric coated. These work pretty well for the majority of us, but sometimes they don't work as well as they should for certain individuals. In this article I will explain what enteric-coated enzymes are, how they are designed to work,  possible reasons why enteric-coated enzymes may not work for certain individuals, and a few options to address this problem.

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Enteric-coated Digestive Enzymes
Prescription-strength pancreatic enzymes are enteric-coated. This means that a certain ingredient coats the outside of the enzyme beads (not the capsule shells themselves) to prevent the enzyme from getting destroyed before entering the small intestine where it needs to be activated. This coating is usually a kind of phthalate. In normal circumstances, the highly acidic environment of the stomach will destroy any enzymes that pass through it. Enzymes should only be activated in the small intestine where a healthy pancreas would normally excrete its pancreatic enzymes. The enteric coating is designed to protect the enzyme in acidic environments and then allow the enzyme to activate once it has reached the alkaline environment of the small intestine.

The small intestine is more alkaline for a specific reason: the pancreas secretes sodium bicarbonate, which is alkaline (basic), when acidic contents (chyme) from the stomach enter the small intestine. Sodium bicarbonate release will only be stimulated upon the small intestine's exposure to acidic chyme. Therefore, if the stomach acid is too low and the chyme is not acidic enough, this may lead to the pancreas not releasing bicarbonate at the right time, thus the digestive enzymes will not be activated. Bicarbonate may not be released into the small intestine at the right time for other reasons which are poorly understood. If either of these problems is occurring, the person may also experience heartburn or GERD, or in severe cases the person may experience burning at the anus upon defecation (if the stool is too acidic as a result of inadequate bicarbonate). I've had clients with both of these issues.

The most common sign that the pancreas is not producing adequate bicarbonate is that enteric-coated pancreatic enzymes will not work very well. By that I mean a person may take these enzymes as prescribed but there may still be steatorrhea (seeing fat or oil in the stools), overall indigestion, malabsorption, and even weight loss. Conventional doctors and CF specialists most often attempt to solve this issue by prescribing proton-pump inhibitors (PPIs) alongside these enteric-coated enzymes to lower the acidity in the stomach in order to allow the enzymes to be activated in the small intestine. There are even certain brands of pancreatic enzymes that contain acid-lowering drugs inside them. However, acid-reducing drugs can have negative side effects as I discuss at length in my articles here and here and in my eBooks.

Alternative Options
If we are concerned about the negative side effects we might experience related to the use of PPIs and other acid-lowering drugs, what other options do we have? Firstly, it's important to address whether or not low stomach acid could be the cause of the issue. By boosting our stomach acid we may be able to alleviate acid reflux, improve our protein digestion, reduce indigestion, and trigger the pancreas to produce its own sodium bicarbonate at the right time. A few ways to boost the stomach acid are to drink 1 tbsp of apple cider vinegar with meals (mixed in a little water), take digestive bitters 5-15 minutes before meals, eat bitter greens before meal, take betaine HCL supplements, or eat acidic fruits like a sour apple or a lemon. I discuss how this works in my articles here and here.

However, if low stomach acid is not the only problem, there is another option as well: using digestive enzyme supplements which are not enteric-coated. This is considered blasphemy to many mainstream docs, as it is a common belief that any digestive enzyme without enteric-coating is completely ineffective as it will be immediately destroyed by the stomach acid. However, if the stomach acid is insufficient, the enzyme may not be destroyed! I have had numerous CF clients with steatorrhea (whose prescription enzymes did not work) use over-the-counter (OTC) non-enteric-coated enzymes with great results. However, I must say that if your stomach acid is normal, OTC enzymes are unlikely to work very well. Why should we attempt to use acid-lowering drugs (which have serious side effects) to activate the enteric coating when a more direct option may be using enzymes with no enteric coating? So far this method has worked for several of my clients with this issue.

Choosing the Right Enzyme
Like anything else available on the market, we must be very picky in choosing which alternative OTC enzyme to use. Not all enzymes available on the market are of equal value--some are absolutely worthless or not suitable for people with CF or pancreatic insufficiency. Therefore, I'd like to give a few guidelines for choosing the right OTC enzyme:

• It must be from a reputable company with high quality testing and third-party certified manufacturing practices.
• It must contain lipase (fat-digesting enzyme), protease (protein-digesting enzyme), and amylase (carbohydrate-digesting enzyme), and have high doses of lipase. Most OTC enzymes on the market do not have enough lipase in them, or have too much amylase and protease (thus a too-high ratio of protease and amylase to lipase).
• Must provide the right dose of lipase without giving too much protease or amylase. The ration of lipase to protease to amylase in prescription enzymes is approximately 1/2.5-3.5/ 3.5-4.25, depending on the brand. In contrast, some OTC enzymes have a ratio of 1/12.5/12.5 or higher, which is not suitable for people with CF.
• We calculate the correct dose of enzymes depending on our weight and the lipase content of the enzyme. (See below).
• Make this transition slowly. I cannot recommend you go off your prescription medication, and certainly not all at once. However we also don't want to take too many enzymes if you're taking both prescription enzymes and OTC ones. Therefore each individual will have to experiment what combination of medications is right for them. You may want to talk with your doctor about this. Be aware that many doctors will try to discourage patients from trying alternative options.
• Most prescription and OTC enzymes are pork-based. There are vegan/vegetarian brands on the market, but they may not work as well.

These are brands of OTC non-enteric-coated enzymes available in the U.S. that I feel meet the necessary specifications above (I have no connections to these companies, these are brands my clients found themselves and used effectively):

1. Metagenics SpectraZyme Pan9x: contains 10,200 USP lipase, 67,500 USP protease, and 67,500 USP amylase per capsule.
2. Pure Encapsulation Pancreatic Enzyme Formula: contains 17,500 USP lipase, 110,000 USP protease, 120,000 USP amylase per capsule.

There are others on the market that may be not as good but still suitable. You may use the guidelines I have written above to find other suitable brands both in the U.S. and in other countries.

Dosing
Enzymes are dosed by the person's weight (in kg) and the amount of lipase contained in the enzyme. According to the CFF, there are several guidelines for enzyme dosing safety:

• Infants generally require 450-900 lipase units/g of fat in a meal, or 2,000-4,000 lipase units per 120 mL of formula or when breastfeeding.
• For humans 12 months to 4 years: standard lipase dose is 1,000 USP/kg/meal.
• For humans 4 years and older: lipase units 500-2,5000 USP/kg/meal
• Doses of more than 6,000 USP lipase/kg/meal is associated with fibrosing colonopathy, a serious intestinal blockage.
  

According to these guidelines you will need to calculate the total lipase daily dose contained in both the prescription enzymes and the OTC ones.

Also, unfortunately many brands do not use the USP units on their labels, which makes it harder to tell if it has the right dose. Here are some conversion rates:

• According to this PMC article:
  • for lipase, 1 FIP/PhEur unit = 1 USP unit;
  • for amylase, 1 FIP/PhEur unit = 4.15 USP units;
  • for protease, 1 FIP/PhEur unit = 62.5 USP units.
• According to this article from Enzyme Essentials:
  • for protease: 1 HUT = approx. 6.5 USP;
  • for amylase: 1 DU = approx. 48 USP;
  • for lipase: 1FIP = approx. 2.5 LU/FCCLU = 1 USP.
• According to this Medscape article:
  • for lipase: 1 IU = 3 USP.

Conclusion
I hope this helps you make an educated decision on whether to use alternative digestive enzymes and how to do it safely. Please share your experiences in the comments below.

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Be well.


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Disclaimer: The content of this website and blog is for educational purposes only and should not be considered medical advice. The information provided here is not intended to replace medical care.