How is exocrine pancreatic insufficiency (EPI) treated?
What to Do When Your EPI Treatment Isn’t Working
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If you’ve been diagnosed with exocrine pancreatic insufficiency (EPI), you’ve probably received guidance about your eating habits and have been prescribed pancreatic digestive enzymes to take with each meal. According to a review published in December 2019 in the journalGut,pancreatic enzyme replacement therapy (PERT) has been shown to be highly effective at improving digestion in people with EPI.
But enzyme therapy isn’t perfect, and despite taking it, many people still have EPI symptoms. As many as 70 percent of people taking enzymes for EPI continue to experience excess fat in their stools (steatorrhea), according to a review published in November 2013 in theWorld Journal of Gastroenterology.
How to Maximize EPI Treatment
If you’re concerned that your treatment for EPI may not be working as it should, make sure you do the following:
- Take your prescribed treatment correctly.In some cases, EPI symptoms persist despite PERT because people misunderstand the instructions about how to correctly time their doses with their meals. “If your EPI isn’t responding well to treatment, it’s possible that you’re not taking the enzymes appropriately,” says Rajesh Keswani, MD, a gastroenterologist and an associate professor of medicine at Northwestern Memorial Hospital in Chicago. This occurs fairly commonly, so don’t feel insulted if your doctor asks you to detail your current enzyme regimen and discovers that you’re not taking the enzymes correctly. Research suggests that the optimal time to take enzymes iswithmeals, not before or after. Ask your doctor to review the specific medication instructions with you.
- Take the correct enzyme dosage.Know your correct dosage and take it as prescribed. But if EPI symptoms continue to bother you, Dr. Keswani says, your doctor may need to increase your enzyme dose. According to the 2013 review in theWorld Journal of Gastroenterology, the large percentage of people treated with PERT who continue to experience excess fat in their stools indicates that their enzyme doses may be too low. In this case, it’s common for doctors to double the dose of enzymes. You should notice the effects of an increased enzyme dose almost immediately, Keswani says. Still, he adds, it’s good to wait a week after making any change to your treatment before evaluating how effective it is. If an increased enzyme dose doesn’t reduce your symptoms, it may be explained by one of two reasons: Either the enzymes aren’t working properly, or you have another condition besides EPI that’s contributing to your symptoms.
- Reduce excess stomach acid.The enzymes taken for EPI can sometimes be destroyed by stomach acid before they reach their intended target in the digestive system. If this occurs, you may need to be prescribed a proton pump inhibitor, a drug that reduces the production of gastric acid. Most of the enzymes for EPI are enteric coated, says Keswani, meaning they’re designed to be protected from breakdown by stomach acid. But in some people, this coating may not work as well; also, some enzymes may not be enteric-coated. In these cases, a proton pump inhibitor may help the enzymes work properly. It’s also possible that a proton pump inhibitor may be needed for a separate condition, Keswani says, such as gastroesophageal reflux disease (GERD), peptic ulcer disease (stomach ulcers), or gastritis.
- Manage gut bacteria.Many people with EPI have an imbalance of gut bacteria, but it’s unclear whether this is directly related to EPI. Says Keswani, “It’s hard to say whether this is a true relationship or just two common things coexisting.” One way to redress an imbalance of gut bacteria is to take probiotic supplements. Keswani says this treatment poses little risk, and he recommends it routinely for people with EPI. Because certain probiotics seem to work better in some people than others, it may take a few tries before you notice any change in your symptoms. Ask your doctor whether probiotics might be beneficial for you, and if so, which supplements you should try.
- Treat conditions other than EPI.It’s common for EPI and another digestive condition to be present at the same time, Keswani says. When a person’s EPI treatment doesn’t seem to be working, doctors often look for celiac disease, irritable bowel syndrome (IBS), and infections as a possible explanation. Tests can determine whether you have any other digestive conditions along with EPI. Work closely with your doctor to ensure that you’re getting the treatment you need to reduce your symptoms and improve your digestive health.
Video: How is your EPI treated?
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