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Digestive Enzymes

Also indexed as: Pancreatic Enzymes, Pancreatin, Papain, Proteolytic Enzymes

Illustration

Digestive enzymes are complex proteins involved in digestion that stimulate chemical changes in other substances. They work optimally at specific temperature and pH. Digestive enzymes include pancreatic enzymes, plant-derived enzymes, and fungal-derived enzymes. There are three classes of digestive enzymes: proteolytic enzymes needed to digest protein, lipases needed to digest fat, and amylases needed to digest carbohydrates.

Where are they found?

Only small amounts of the animal-based proteolytic enzymes, trypsin and chymotrypsin, are found in the diet; however, the pancreas can synthesize these enzymes. The plant-based proteolytic enzyme bromelain comes from the stems of pineapples and is useful in many conditions. Papain comes from unripe papayas. All of these enzymes are available as supplements.

Enzymes have been used in connection with the following conditions (refer to the individual health concern for complete information):

Science Ratings Health Concerns
3Stars

Low back pain (chymotrypsin, trypsin)

Pancreatic insufficiency (including pancreatitis)

Sprains and strains (chymotrypsin, trypsin)

2Stars

Celiac disease

Indigestion (Lipase)

Osteoarthritis (bromelain, trypsin, rutosid combination)

Tendinitis (proteolytic enzymes)

1Star

Acne Rosacea

Chronic candidiasis

Crohn’s disease

Food allergies

Gastroesophageal reflux disease (GERD)

Low back pain (papain)

Sprains and strains (papain)

3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

Who is likely to be deficient?

People with pancreatic insufficiency and cystic fibrosis frequently require supplemental pancreatic enzymes (which include proteolytic enzymes, lipases, and amylases). In addition, those with celiac disease1 or Crohn’s disease2 and perhaps some people suffering from indigestion3 may be deficient in pancreatic enzymes. As bromelain and papain are not essential, deficiencies do not exist.

How much is usually taken?

The digestive enzymes—proteolytic enzymes, lipases, and amylases—are generally taken together. Pancreatin, which contains all three digestive enzymes, is rated against a standard established by the U.S. Pharmacopeia (USP). For example, “4X pancreatin” is four times stronger than the USP standard. Each “X” contains 25 USP units of amylase, 2 USP units of lipase, and 25 USP units of protease (or proteolytic enzymes). Three to four grams of 4X pancreatin (or a lower amount at higher potency) with each meal is likely to help digest food in some people with pancreatic insufficiency.

Those with chronic pancreatitis need to discuss enzyme intakes with their physician. Under medical supervision, seriously ill people with pancreatic insufficiency caused by pancreatitis are given very high levels of enzymes to improve fat digestion. In one successful trial, enough pancreatin was used with each meal to supply slightly over 1,000,000 USP units of lipase.4 Because pancreatin is rapidly emptied from the stomach during digestion, people taking these enzymes may obtain better results by spreading out supplementation throughout the meal.5

Supplemental enzymes that state only product weight, but not activity units, may lack potency.

Are there any side effects or interactions?

The most important digestive enzymes in malabsorption diseases are usually fat-digesting enzymes called lipases. Proteolytic enzymes can digest, as well as destroy, lipases. Therefore, people with enzyme deficiencies may want to avoid proteolytic enzymes in order to spare lipases.6 If this is not possible (as most enzyme products contain both), people with malabsorption syndromes should talk with their doctor to see if their condition warrants finding products that contain the most lipase and the least protease.

In theory, too much enzyme activity could be irritating because it could start to “digest” parts of the body as the enzymes travel through the digestive system. Fortunately, that does not happen with supplemental amounts. Research has not determined the level at which such problems might arise.

A serious condition involving damage to the large intestines called fibrosing colonopathy has resulted from the use of pancreatic enzymes in children with cystic fibrosis. In some cases, the problem was linked to the use of high supplemental amounts of enzymes.7 8 9 However, the amount of enzymes used has not been linked to the problem in all reports.10 In some cases, lower amounts of enzymes have caused fibrosing colonopathy if the enzymes are enteric-coated.11 Some researchers now believe that some unknown interaction between the enteric coating and the enzymes themselves may cause damage to the intestines of children with cystic fibrosis.12 Until more is known, children with cystic fibrosis needing to take pancreatic enzymes should only do so under the careful supervision of a knowledgeable healthcare professional.

Are there any drug interactions?
Certain medicines may interact with digestive enzymes. Refer to drug interactions for a list of those medicines.

References:

1. Patel RS, Johlin FC Jr, Murray JA. Celiac disease and recurrent pancreatitis. Gastrointest Endosc 1999;50:823–7.

2. Gullo L. Indication for pancreatic enzyme treatment in non-pancreatic digestive diseases. Digestion 1993;54(suppl 2):43–7.

3. Suarez F, Levitt MD, Adshead J, Barkin JS. Pancreatic supplements reduce symptomatic response of healthy subjects to a high fat meal. Dig Dis Sci 1999;44:1317–21.

4. Nakamura T, Tandoh Y, Terada A, et al. Effects of high-lipase pancreatin on fecal fat, neutral sterol, bile acid, and short-chain fatty acid excretion in patients with pancreatic insufficiency resulting from chronic pancreatitis. Int J Pancreatol 1998;23:63–70.

5. Taylor CJ, Hillel PG, Ghosal S, et al. Gastric emptying and intestinal transit of pancreatic enzyme supplements in cystic fibrosis. Arch Dis Child 1999;80:149–52.

6. Layer P, Groger G. Fate of pancreatic enzymes in the human intestinal lumen in health and pancreatic insufficiency. Digestion 1993;54(suppl 2):10–4.

7. Stevens JC, Maguiness KM, Hollingsworth J, et al. Pancreatic enzyme supplementation in cystic fibrosis patients before and after fibrosing colonopathy. J Pediatr Gastroenterol Nutr 1998;26:80–4.

8. Oades PJ, Bush A, Ong PS, Brereton RJ. High-strength pancreatic enzyme supplements and large-bowel stricture in cystic fibrosis. Lancet 1994;343:109 [letter].

9. Campbell CA, Forrest J, Muscgrove C. High-strength pancreatic enzyme supplements and large-bowel stricture in cystic fibrosis. Lancet 1994;343:109–10 [letter].

10. Milla CE, Wielinski CL, Warwick WJ. High-strength pancreatic enzymes. Lancet 1994;343:599 [letter].

11. Jones R, Franklin K, Spicer R, Berry J. Colonic strictures in children with cystic fibrosis on low-strength pancreatic enzymes. Lancet 1995;346:499–500 [letter].

12. Powell CJ. Pancreatic enzymes and fibrosing colonopathy. Lancet 1999;354:251 [letter].

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