15
Table 12. Factors That Affect Oral Pancreatic Enzyme Efficacy
• Enzymes are dosed inadequately.
• Enzyme is outdated.
• Delayed gastric emptying causes poor mixing of enzymes with food and prolonged
exposure to gastric acid.
• Rapid small bowel transit reduces mucosal contact time.
• Timing of enzymes is inappropriate such as taking at completion of meal instead of at
beginning/during meal.
• Gastric and intestinal environment is too acidic. The optimal pH for enzyme
activation is >5.5 (lipase is irreversibly inactivated at pH of <4). Therefore, an acid-
suppressing agent may be needed.
• Enzymes are improperly stored (exposed to heat—e.g., in the car, in a clothing pocket)
or taken with hot drinks, which can denature enzymes.
• Over-the-counter generic enzymes are used and are not bioequivalent to prescription
enzymes.
• Enzyme capsule contents are chewed or crushed.
• Delayed dissolution of enteric-coated enzyme capsule contents in the small bowel
shifts absorption sites distally.
• Capsule contents have prolonged exposure to alkaline foods or fluids.
• Patient does not take enzymes as prescribed.
Notes:
• All PERT work optimally in pH >5.5. Proton pump inhibitors produce 90% reduction in acid
secretion vs. only 50% with H2 receptor antagonists.
• PERT activity peaks about 30 minutes after ingestion and last about 2 hours.
Table 11. Sodium Bicarbonate Sources for Mixing with
Pancreatic Enzymes
Source mEq bicarb and sodium
Sodium bicarbonate solution
• 8.4% solution (84 mg/mL)
• 650 mg tablet dissolved in 65 mL of water
• 325 mg tablet in 40 mL water
• 1 mEq/mL each of bicarbonate
& Na
Sodium bicarbonate powder
(same as baking soda)
• 500 mg
• 650 mg
• 6.2 mEq each of bicarbonate and Na
• 7.7 mEq each of bicarbonate and Na
Baking soda (from your kitchen)
• 1/8 teaspoon • 6.7 mEq each of bicarbonate and Na
Notes:
• For each 10,000 units of lipase, 10 mL of 8.4% sodium bicarbonate is recommended.
• Monitor basic metabolic panel for serum bicarbonate level to ensure patient does not become
alkalotic on sodium bicarbonate dose.
• Do not use calcium carbonate or magnesium aluminum hydroxide antacids as both have been
shown to reverse the beneficial effects of enzyme therapy by causing precipitation of calcium and
magnesium soaps.
