Rational Use of Pancreatic Enzymes for Pancreatic Insufficiency and Pancreatic Pain

  • Gyanprakash A. Ketwaroo
  • David Y. GrahamEmail author
Part of the Advances in Experimental Medicine and Biology book series (AEMB, volume 1148)


We describe the rational use of enteric coated and unprotected replacement pancreatic enzymes for treatment of malabsorption due to pancreatic insufficiency and for pancreatic pain. Enteric coated formulations mix poorly with food allowing separation of enzymes and nutrients when emptying from the stomach. The site of dissolution of the enteric coating in the intestine is also unpredictable and enzymes may not be released until the distal intestine. Together, these barriers result in the lack of dose-response such that the strategy of increasing the dosage following a suboptimal effect is often ineffective. The ability to maintain the intragastric pH ≥4 with the combination of proton pump inhibitors and antacids suggests that it should be possible to reliably obtain a good response with uncoated enzymes. We also discuss the recognition, treatment and prevention of nutritional deficiencies associated with pancreatic insufficiency and recommend a test and treat strategy to identify and resolve nutritional deficits. Finally, we focus on mechanisms causing pain that may be amenable to therapy with pancreatic enzymes. Pain due to malabsorbed digestive contents can be prevented by successful therapy of malabsorption. Feedback inhibition of endogenous pancreatic secretion can prevent pain associated with pancreatic secretion but requires use of non-enteric coated formulations.


Pancreatic enzymes Pancreatic insufficiency Chronic pancreatitis 





Coefficient of fat absorption


Food and Drug Administration


International normalized ratio


Retinol binding protein



Dr. Graham is in part by the Research Service Department of Veterans Affairs and by Public Health Service grant DK56338 which funds the Texas Medical Center Digestive Diseases Center. The authors acknowledge the excellent advice received from Temitope Osinaiya, DHSc, MS, RD, LDN regarding the nutritional assessment of patients with pancreatic insufficiency.

Competing Interests

Dr. Graham is a consultant for RedHill Biopharma regarding novel H. pylori therapies and has received research support for culture of Helicobacter pylori and is the PI of an international study of the use of antimycobacterial therapy for Crohn’s disease. He is also a consultant for BioGaia in relation to probiotic therapy for H. pylori infection and for Takeda in relation to H. pylori therapies. Dr. Ketwaroo does not have any relevant disclosures.


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© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Department of Medicine, Michael E. DeBakey VA Medical CenterBaylor College of MedicineHoustonUSA

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