Arjun Gupta, MD, is a chief fellow in the Johns Hopkins Hematology/Oncology Fellowship. His academic interests include gastrointestinal cancers, supportive care, and identifying and reducing the hidden side effects of cancer care. You can follow Dr. Gupta on Twitter. View Dr. Gupta’s disclosures.

Pancreatic enzymes, such as amylase, trypsin, and lipase, are chemicals produced by the pancreas that help digest food. If the pancreas cannot produce or release enough of these enzymes, a person is unable to completely digest food, which can lead to problematic symptoms. When this happens, it is called pancreatic enzyme insufficiency. People with pancreatic enzyme insufficiency need to have their digestive pancreatic enzymes replaced from outside the body, which is a treatment called pancreatic enzyme replacement therapy, or PERT.

Why might someone with cancer need pancreatic enzyme replacement therapy?

People with pancreatic cancer are more likely to need pancreatic enzyme replacement therapy for several reasons. First, pancreatic cancer can itself damage the pancreas and block the flow of pancreatic enzymes into the intestine, which is where food is normally digested. Surgically removing the pancreas and parts of the intestine to treat pancreatic cancer or other types of cancer can also lead to pancreatic enzyme deficiency. In addition, certain tumors can produce high levels of stomach acid, which can make pancreatic enzymes ineffective.

People with cancer who develop pancreatic disease from other causes, such as chronic pancreatitis (where the pancreas is inflamed) or cystic fibrosis (which produces a mucus that can block the ducts in the pancreas), may also require pancreatic enzyme replacement therapy.

What are the symptoms of pancreatic enzyme insufficiency?

When food is not properly digested and absorbed, it can lead to symptoms such as:

  • Belly pain and cramping

  • Gas (flatulence) and bloating

  • Loose, oily, foul-smelling stool

  • Stool that floats in the toilet bowl or is difficult to flush

  • Weight loss

People with pancreatic enzyme insufficiency can also develop deficiencies in key vitamins and nutrients. By receiving pancreatic enzyme replacement therapy, these symptoms can be improved.

How is pancreatic enzyme insufficiency diagnosed?

The symptoms of pancreatic enzyme insufficiency can overlap with other conditions. For example, chemotherapy can also cause loose stools and diarrhea. Cancer itself can cause stomach pain and weight loss. This is why it’s important to report your symptoms to your health care team right away. Your doctor can usually determine whether you need pancreatic enzyme replacement therapy by speaking to you and performing a physical examination. Further testing is usually not required, though levels of pancreatic enzymes can be tested in the stool, if needed. If your doctor suspects you may have pancreatic enzyme insufficiency, they may prescribe pancreatic enzyme replacement therapy.

How is pancreatic enzyme replacement therapy given?

Pancreatic enzyme replacement therapy involves giving medications by mouth (capsules or tablets). These medications need to be taken with almost all meals, including snacks and supplemental drinks. The medication must be swallowed whole (not crushed or chewed) with a room-temperature or cold drink. Hot temperatures can damage the pancreatic enzymes in the medications.

If a person has difficulty swallowing capsules, they can open a capsule, sprinkle the granules over food such as applesauce or yogurt, and consume it quickly, followed by a drink. More than 1 capsule or tablet may need to be taken per meal. If that is the case, the first capsule or tablet must be consumed with the first bite of the meal and the rest should be consumed in the middle of the meal. This ensures that the enzymes get well mixed with the food. Talk with your doctor about which dose is most appropriate for you.

What are some of the side effects of pancreatic enzyme replacement therapy?

Pancreatic enzyme replacement therapy is generally safe when taken at prescribed doses. However, taking very high doses for a prolonged period of time may damage the intestine and lead to worsening abdominal symptoms or weight loss.

What diet and lifestyle changes should I follow if I am receiving pancreatic enzyme replacement therapy?

If you are receiving pancreatic enzyme replacement therapy, you should:

  • Keep a log of meals, symptoms, and pancreatic enzyme replacement therapy use. This can help determine if the medications are helping you and if the dose needs to be changed.

  • Avoid smoking and limit drinking alcohol.

  • Take vitamins and acid-blocking medications, if your health care team recommends it.

What are other things I should consider while receiving pancreatic enzyme replacement therapy?

There are several prescription brand medications for pancreatic enzyme replacement therapy, and they can be expensive. Because of the cost, some people may consider using cheaper, over-the-counter preparations of pancreatic enzymes. However, these over-the-counter medications are not regulated and may have very low enzyme content. Do not use them to replace prescribed therapy. Let your health care team know if you have trouble paying for your medications. They may be able to direct you to resources to help with the cost of treatment.

Vegetarians and followers of any religion that avoid pork products specifically or animal products in general should also know that current pancreatic enzyme replacement therapy formulations are derived from pig pancreas.