What Are Pancreatic Enzymes?
IBS & Pancreatic Enzymes
Why might we need pancreatic enzymes for IBS?
Although researchers are still looking into ways in which pancreatic enzymes may help those with IBS, the primary thought is that some people may have an issue where their pancreas is not making and/or releasing enough enzymes to digest the food they are eating.
This disorder is referred to as exocrine pancreatic insufficiency (EPI).
EPI is very common in conditions such as cystic fibrosis and pancreatitis but can be caused by a number of other disorders as well. Symptoms of severe EPI include smelly, fatty stools (a.k.a steatorrhea), weight loss, muscle wasting, gassiness, micronutrient deficiencies, as well as abdominal pain and diarrhea– something our IBS-D & M friends know a little bit about.12
How to test for Exocrine Pancreatic Insufficiency (EPI)
- There are a few ways that doctors can check for EPI, but the go-to test in most clinical settings is fecal elastase-1 (FE-1).
- FE-1 is an indirect test of pancreatic function that is pretty good at identifying severe EPI; however, it is less accurate in mild and moderate cases.2
- Additionally, there is concern that it over-diagnoses EPI in people who have diarrhea if the stool sample is too watery.
- There are better tests out there, but unfortunately, they’re not as widely available and/or practical.3
Why EPI is ignored for most IBS patients
Checking for EPI when diagnosing IBS is currently not standard practice for most physicians, even though the prevalence of low FE-1 levels (< 200 mcg/g stool) in IBS has been found to be around 5-13%.456
Why don’t more docs check for EPI? Well, it’s complicated (as always).
- Part of the issue probably is some lack of awareness since very few studies have looked at EPI in IBS.
- Checking for EPI also isn’t recommended by clinical practice guidelines for IBS, such as the recent one published by the American College of Gastroenterology (ACG).
- Some also feel that the prevalence of EPI is too low and not worth checking in most cases, especially considering the issues around testing for EPI that we talked about earlier.
Do Pancreatic Enzymes Help IBS?
Okay time to dive into the studies. Now, we have to warn you, summarizing the current research on pancreatic enzyme supplementation in IBS is rather difficult. For reasons unknown, it seems IBS researchers get a kick out of designing the most complicated study protocols ever. I mean, is it too much to ask for at least one straightforward, double-blind, randomized, placebo-controlled trial looking just at pancreatic enzymes and IBS patients? Apparently so.
With that said, based on the evidence we have so far, complicated as it may be, it does seem like supplementing with these enzymes can be helpful for a subgroup of people with IBS.
2010 study - UK
One of the largest studies to date supporting the use of pancreatic enzymes in IBS comes from a UK study published in 2010.8
- In this study, researchers first tested for EPI by checking FE-1 in 314 people with IBS-D.
- After testing, they found that 19 of the IBS-D participants (6.1%) came back with severely low FE-1 levels (<100 mcg/g stool).
- The researchers then went on and gave the IBS-D participants Creon, a prescription blend of pancreatic enzymes that includes lipase, amylase, and proteases.
- Dosing of pancreatic enzymes such as Creon are based on lipase content, and in this study, a dose containing 30,000 USP lipase units three times a day was used.
- The pancreatic enzymes significantly improved stool frequency, consistency, and pain in the IBS-D participants with EPI compared to the IBS-D participants with normal FE-1 levels.
- As impressive as these results were, we have to keep in mind that this was not a well controlled study. No placebo was used and participants knew they were getting enzymes, so it’s impossible to know how much the placebo effect played into the results.
2022 study - Argentina
A study pretty similar to the UK study was published in 2022 by a group from Argentina.6
- Of the 140 IBS-D patients tested, 7 (5%) had severely low FE-1 levels and were considered to have EPI.
- After supplementing with Creon at a dose containing 50,000 USP units of lipase with meals and 25,000 USP units of lipase with snacks for 12 weeks, all of the people with EPI demonstrated significant improvements in stool frequency, stool consistency, abdominal pain, distention, and IBS severity score.
- They also found that dyspepsia, a medical term for indigestion or the presence of stomach discomfort after eating, was strongly associated with EPI. This is a helpful finding, as it’s a symptom that could assist doctors in narrowing down who is most likely to have EPI and might respond best to enzyme supplementation.
2011 study - USA
A third and rather unique study that is referenced quite a bit in the literature looked at pancreatic enzyme supplementation in IBS-D patients who reported at least 2 trigger foods that consistently induced symptoms.9
- Participants were instructed to take 1-3 capsules of enzymes or placebo with at least 4 triggering meals each.
- A pancreatic enzyme medication known as Viokase was used in this study, containing 8000 units of lipase per capsule.
- After completing both placebo and enzyme capsules, participants were then asked to choose which capsules they felt worked better.
- Of the 39 people who completed the study, 25 (64%) chose the enzyme capsules over the placebo capsules.
- In the enzyme-choice group, global symptom scores were significantly reduced when taking the enzyme compared to placebo, as well as scores for cramping, bloating, borborygmi (stomach gurgling), urgency, and pain.
- FE-1 levels were measured in some of the participants, but only 4 were found to have even moderately low levels (between 100-200 mcg/g).
- Interestingly, 3 of the 4 people with low FE-1 levels ended up picking the placebo as their preferred capsule. Hard to know what to make of this particular finding. It’s possible the dose of enzymes they were taking wasn’t enough to make a difference in their symptoms. It’s also possible that the enzymes just aren’t super helpful for people with only moderately low FE-1 levels.
- Either way, in general, the results from this study seem to suggest that pancreatic enzymes may be helpful for some people with IBS-D, even if FE-1 levels are normal.
2012 review - USA
The last piece of evidence we’ll share from the published literature actually comes from a review discussing the treatment of post-prandial diarrhea, or in other words, diarrhea occurring after meals.
- In this review, one of the authors reported data from her clinic in which pancreatic enzymes were used to treat 144 IBS patients with post-prandial diarrhea.
- Of the 86 she was able to follow up with, 71 (82.5%) reported that the treatment had either improved or eliminated symptoms.
- While this was a retrospective review and not a well-controlled clinical trial by any means, it does add to the weight of evidence that supports trying out pancreatic enzymes for those regularly experiencing post-meal diarrhea.
The takeaway from these studies
While these studies may seem a bit random and all over the place, put together, they do start to paint a picture of where pancreatic enzyme supplementation fits into treating IBS.
Isolating who is most likely to benefit from pancreatic enzymes is tricky, but the evidence does seem to suggest that IBS-D patients with dyspepsia and/or post-prandial diarrhea are more likely to benefit from pancreatic enzyme supplementation.
Whether or not it’s worth checking FE-1 levels is still debatable. This is because the results may not be super trustworthy, but also because it appears that taking pancreatic enzymes may be helpful even without a diagnosis of EPI.
The reality is that there also aren’t too many downsides to just doing a trial of pancreatic enzymes if you are someone who frequently experiences symptoms following meals, as they have been shown to be very safe for most people.1
Although, for most of this guide, we’ve specifically addressed pancreatic enzyme supplementation in the context of EPI, it’s possible that enzyme supplementation may be helpful in improving IBS symptoms for reasons that aren’t understood yet.
For example, why have some people without a diagnosis of EPI still shown benefits from supplementing with pancreatic enzymes? Do these enzymes have an effect on the activity of other enzymes or digestive processes which help to improve IBS symptoms?
Adding to this, the doses and formulations that have been trialed successfully vary a ton, leaving us scratching our heads about where to begin when trying these enzymes. Clearly, the evidence on pancreatic enzymes in IBS has a long way to go.
For now, we can say that pancreatic enzymes appear safe and may be worth talking with your doctor about, especially for IBS patients with frequent indigestion or after-meal pain and diarrhea.
How To Take Pancreatic Enzymes For IBS
How much to take (dosing)
When it comes to dosing pancreatic enzymes, as you know by now, we really don’t have a lot of IBS-specific research. Not only that, but the participants in the studies we do have were taking a wide range of doses, anywhere from 8,000 to 50,000 lipase units per meal, depending on the study.
With that said, pancreatic enzymes replacement therapy (PERT) is to treat a number of conditions other than IBS). Because of this, we do have a bit more information on pancreatic enzymes than we do other types of digestive enzymes.
Here are some general tips:
- As always, consult your doctor before starting or stopping medications or supplements of any kind.
- Like we mentioned before, pancreatic enzyme dosing is based on lipase units, although they should also contain amylase and proteases.
- The amount needed to see clinical benefit will vary from person to person.
- The fat, protein, and carbohydrate content of your meals likely will also change how much enzyme is needed.
- The recommended starting dose for adults with EPI varies significantly and is brand specific, but generally the starting ranges for PERT in EPI are around 20,000 to 50,000 lipase units per meal.1
- The recommended dose for snacks is usually half of the dose for meals
- It may be helpful to spread out the enzymes throughout the meal instead of taking them all at once.2
- Medications such as proton pump inhibitors (PPIs) are sometimes added to optimize enzyme activity. These medications decrease the amount of stomach acid being made, which can help make sure the pH of the food going through your intestines isn’t too low for the enzymes.
- Did I already mention that you should talk to your doctor first? Yes? Okay, just checking.
How to buy pancreatic enzymes
Only 6 pancreatic enzyme products have been approved by the Food and Drug Administration (FDA). These include Creon, Zenep, Pancreaze, Ultresa, Viokace, and Pertzye. 3It’s definitely ideal to use a brand of pancreatic enzymes approved by the FDA, so you know that you are getting a product that has been shown to be safe, effective, and contains consistent dosages of enzymes.
These products require a prescription from your doctor, and won’t be cheap to pay out of pocket, so having insurance to help cover costs will be important.
If your insurance won’t cover a prescription, over-the-counter digestive enzyme supplements that contain pancreatic enzymes do exist.