Pancreatic enzymes
Pancreatin/Drug Interactions:
AnalgesicsAnalgesics: In human research, pancreatin was associated with a reduction in pain due to chronic pancreatitis (66; 67). The addition of analgesics to pancreatin treatment of patients with chronic pancreatitis has been discussed in a review (68). AntacidsAntacids: Based on secondary sources, calcium carbonate- and magnesium hydroxide-containing antacids may be required to prevent inactivation of non-enteric-coated pancrelipase. However, these agents may reduce the effectiveness of pancreatic enzymes.Antidiabetic agentsAntidiabetic agents: In patients with diabetes, changing treatment from pancreatin to placebo and vice versa resulted in major problems with glucose control (abnormal glucose control in 28 of 29 patients, one patient requiring hospitalization for symptomatic hypoglycemia, and one patient developing diabetic ketoacidosis) (26). Pancreatin had no effect on HbA1c, fasting glucose, two-hour postprandial glucose, C-peptide, glucagon, or PP plasma levels, in other research (69; 70). Based on secondary sources, enzymes in pancreatin may reduce the efficacy of acarbose. AntineoplasticsAntineoplastics: In vitro, a polyenzyme preparation containing pancreatin, papain, bromelain, trypsin, and chymotrypsin enhanced release of reactive oxygen species by neutrophils, potentially acting as an anticancer agent (71). The effects of pancreatin alone cannot be determined from this study. Dehydrocholic acidDehydrocholic acid: A combination of fentonium chloride, dehydrocholic acid, pancreatin, and lactulose reduced symptoms of digestive disorders to a greater extent than fentonium bromide alone, or a combination of the other three ingredients (1). DimethylpolysiloxaneDimethylpolysiloxane: A combination of pancreatin and dimethylpolysiloxane has been studied as a therapy for complex digestive disorders (72). Fentonium chlorideFentonium chloride: A combination of fentonium chloride, dehydrocholic acid, pancreatin, and lactulose reduced symptoms of digestive disorders to a greater extent than fentonium bromide alone, or a combination of the other three ingredients (1). Folic acidFolic acid: In human research, pancreatic enzymes were associated with decreased absorption of folate, and increased folic acid supplementation may be necessary (44). H2 blockersH2 blockers: In human research, ranitidine was preferable to enprostil, in terms of side effects and efficacy, as an adjunct in patients also treated with pancreatin (73). The addition of H2 receptor antagonists to pancreatin supplementation improved fecal fat excretion in patients with steatorrhea (74; 75; 76; 77; 78; 79). The combination of cimetidine and pancreatic extract resulted in meconium ileus equivalent in a child with cystic fibrosis (80). The use of H2 receptor antagonists as adjunct to pancreatin supplements has been discussed in reviews (18; 81; 82). Iron saltsIron salts: The effect of pancreatin on iron absorption has been investigated (83). Based on secondary sources, pancreatic enzymes may be reduced by oral iron supplementation. LactuloseLactulose: A combination of fentonium chloride, dehydrocholic acid, pancreatin, and lactulose reduced symptoms of digestive disorders to a greater extent than fentonium bromide alone, or a combination of the other three ingredients (1). MisoprostolMisoprostol: In human research, misoprostol, an inhibitor of gastric acid production, improved the efficacy of pancreatic enzymes when administered concurrently (84). Proton pump inhibitors (PPIs)Proton pump inhibitors (PPIs): The addition of omeprazole to high-dose pancreatin supplementation improved fecal fat excretion in patients with steatorrhea (85; 74). In further clinical research, the investigation of pancreatin was conducted with all subjects using omeprazole (86). The use of proton pump inhibitors as an adjunct to pancreatin supplements has been discussed in reviews (18; 87). Pancreatin/Herb/Supplement Interactions:
AnalgesicsAnalgesics: In human research, pancreatin was associated with a reduction in pain due to chronic pancreatitis (66; 67). The addition of analgesics to pancreatin treatment of patients with chronic pancreatitis has been discussed in a review (68). AntacidsAntacids: Based on secondary sources, calcium carbonate- and magnesium hydroxide-containing antacids may be required to prevent inactivation of non-enteric-coated pancrelipase. However, these agents may reduce the effectiveness of pancreatic enzymes.AntineoplasticsAntineoplastics: In vitro, a polyenzyme preparation containing pancreatin, papain, bromelain, trypsin, and chymotrypsin enhanced release of reactive oxygen species by neutrophils, potentially acting as an anticancer agent (71). BromelainBromelain: A combination product containing bromelain and pancreatin offered slight improvement over pancreatin alone in human research of pancreatic insufficiency (88). Fat-soluble vitamins (A, D, E, K)Fat-soluble vitamins (A, D, E, K): The effect of pancreatin on levels of fat-soluble vitamins has been investigated in patients with chronic pancreatitis and exocrine pancreatic insufficiency, as these conditions may cause deficiency in fat-soluble vitamins (89; 90; 91). Based on secondary sources, pancreatic enzymes may improve the deficiency, but vitamin supplementation is typically also required. Folic acidFolic acid: In human research, pancreatic enzymes were associated with decreased absorption of folate, and increased folic acid supplementation may be necessary (44). HypoglycemicsHypoglycemics: In patients with diabetes, changing treatment from pancreatin to placebo and vice versa resulted in major problems with glucose control (abnormal glucose control in 28 of 29 patients, one patient requiring hospitalization for symptomatic hypoglycemia, and one patient developing diabetic ketoacidosis) (26). Pancreatin had no effect on HbA1c, fasting glucose, two-hour postprandial glucose, C-peptide, glucagon, or PP plasma levels, in other research (69; 70). IronIron: The effect of pancreatin on iron absorption has been investigated (83). Based on secondary sources, pancreatic enzymes may be reduced by oral iron supplementation. Picolinic acidPicolinic acid: In a human case report, the picolinic acid content of a pancreatin supplement (Viokase?), and not its pancreatin content, was thought to be associated with a correction of a deficiency of carboxypeptidase enzyme (15). ZincZinc: In a human case report, the zinc content of a pancreatin supplement (Viokase?), and not its pancreatin content, was thought to be associated with a correction of a deficiency of carboxypeptidase enzyme (15). Pancreatin/Food Interactions:
Acidic foodsAcidic foods: Acidic foods, such as apple sauce and fruit juice, may lead to the breakdown of enzymes and decrease the activity of pancreatin (92). Alkaline foodsAlkaline foods: Theoretically, alkaline foods may destroy enteric-coated formulations of pancreatin, although such evidence is lacking.Cooled potatoCooled potato: In vitro, pancreatin was unable to completely digest cooled potato (93). The clinical significance of this is unknown. Foods high in folic acidFoods high in folic acid: In human research, pancreatic enzymes were associated with decreased absorption of folate, and increased folic acid supplementation may be necessary (44). High caloric intakeHigh caloric intake: In patients with pancreatic insufficiency due to cystic fibrosis, patients may also need to increase overall caloric intake by 120-150% in order to increase weight and absorption of nutrients, due to limited availability (94). It is possible that caloric intake may be decreased in patients using pancreatin; however, this would have to be determined by the medical practitioner in charge. Iron-containing foodsIron-containing foods: The effect of pancreatin on iron absorption has been investigated (83). Based on secondary sources, pancreatic enzymes may be reduced by oral iron supplementation. Zinc-containing foodsZinc-containing foods: In a human case report, the zinc content of a pancreatin supplement (Viokase?), and not its pancreatin content, was thought to be associated with a correction of a deficiency of carboxypeptidase enzyme (15). Pancreatin/Lab Interactions:
Blood glucoseBlood glucose: In a double-blind trial of pancreatic enzyme therapy vs. placebo in patients with unresectable pancreatic cancer and associated pancreatic duct obstruction, one patient developed diabetes during the study period (25). In patients with diabetes, changing treatment from pancreatin to placebo and vice versa resulted in major problems with glucose control (abnormal glucose control in 28 of 29 patients, one patient requiring hospitalization for symptomatic hypoglycemia, and one patient developing diabetic ketoacidosis) (26). Folic acidFolic acid: In human research, pancreatic enzymes were associated with decreased absorption of folate (44). Gastrointestinal hormonesGastrointestinal hormones: According to a review, pancreatin may influence the release of various gastrointestinal hormones (cholecystokinin, motilin, gastric inhibitory polypeptide) (12). In human research, high-dose substitution with pancreatic enzymes (4.2g of pancreatin) reduced elevated cholecystokinin levels by 38% (95). Long-term therapy with oral pancreatic enzymes reduced postprandial cholecystokinin levels (96). IronIron: The effect of pancreatin on iron levels has been investigated (83). Based on secondary sources, pancreatic enzymes may be reduced by oral iron supplementation. LactaseLactase: Pancreatin significantly decreased intestinal lactase activity in human research and in vitro (97). Pancreatic polypeptidePancreatic polypeptide: Pancreatin may lead to an increased release of pancreatic polypeptide (12). Trypsin and lipaseTrypsin and lipase: In human research, use of pancreatic enzymes increased intestinal levels of trypsin and lipase (98). In human research, pancreatin was associated with a lower mean concentration and recovery of lipase and trypsin activity in the postprandial duodenal samples (99). When administered to 20 healthy male volunteers, enteric-coated pancreatic enzyme capsules (Panzytrat?) were shown to significantly inhibit postprandial pancreatic secretion (100). No effect on intestinal trypsin and lipase was observed in one study (101). Uric acid (serum and urine)Uric acid (serum and urine): High doses of pancreatin have been shown to cause hyperuricemia and hyperuricosuria (43; 102). UrinalysisUrinalysis: High doses of pancreatin have been shown to cause crystalluria (42).