Pancreatic enzyme replacement therapy (PERT) is a cornerstone of care for individuals with pancreatic exocrine insufficiency (PEI). However, finding the right dose can be challenging, especially with the limited options available in New Zealand: Creon 10,000 and Creon 25,000. Let’s explore why dosing can be tricky and how to navigate these challenges effectively.

What Are Pancreatic Enzymes?

Pancreatic enzymes are essential for digesting fats, proteins, and carbohydrates. In conditions like chronic pancreatitis, cystic fibrosis, or after pancreatic surgery, the pancreas doesn’t produce enough enzymes, leading to symptoms like steatorrhea (fatty stools), bloating, and malnutrition. Creon capsules contain pancreatic enzymes encased in microgranules with a pH-sensitive coating. This ensures the enzymes are released where they’re most effective: the small intestine.

The Importance of Treating Pancreatic Exocrine Insufficiency (PEI)

Undiagnosed pancreatic exocrine insufficiency (PEI) results in malabsorption, which can quickly lead to gastrointestinal symptoms, weight loss, malnutrition, osteoporosis, and fat-soluble vitamin deficiencies. PERT eliminates this malabsorption and its consequences by mimicking the exocrine secretory response of a healthy pancreas.

Dosing and administration of PERT are inextricably linked to diet, meaning that dietitians are ideally placed to prescribe and monitor this therapy. This collaboration ensures that patients receive optimal care tailored to their nutritional needs.

Recommended Starting Dose

The initial recommended dose of pancreatic enzymes is:

• 40,000 to 50,000 units of lipase per meal
• 25,000 units of lipase per snack

These doses are guidelines and often require individual adjustments based on symptom relief and dietary patterns.

Why Dosing Can Be Challenging

1. Individual Variation: Every person’s needs are different. Factors such as meal size, fat content, and the severity of PEI affect dosing requirements.
2. Steatorrhea Management: The primary goal is to reduce steatorrhea. This might require increasing the dose until symptoms improve.
3. Limited Formulations: In New Zealand, only Creon 10,000 and Creon 25,000 are available. This means patients may need to take multiple capsules to reach the optimal dose.
4. Meal Composition: High-fat meals require higher doses. Patients must learn to adjust their enzyme intake based on what they’re eating.

Tips for Optimising Pancreatic Enzyme Dosing

1. Start Low and Adjust Gradually: Begin with the recommended dose and increase gradually until symptoms improve. Keep a food and symptom diary to track progress.
2. Split Doses During Meals: For large meals, consider splitting the dose and taking half at the start and the other half midway through the meal.
3. Educate Yourself: Learn to adjust doses based on meal size and fat content. For instance, a small salad may require less Creon than a rich pasta dish.
4. Monitor Symptoms: If symptoms like bloating, gas, or steatorrhea persist, it might mean the dose needs to be adjusted.
5. Avoid Excessive Dosing: Taking more enzymes than needed doesn’t necessarily improve digestion and can result in a significant pill burden. Work with your healthcare team to find the right balance.

When to Seek Help

If you’re not seeing improvements despite adjusting your dose, consult with a specialist dietitian prescriber. They may:

• Recommend investigations for other underlying issues, such as small intestinal bacterial overgrowth (SIBO) or bile acid malabsorption.
• Recommend additional dietary modifications.
• Adjust your Creon dosing or administration, or recommend other medications that can improve the efficacy of Creon.

Supporting Your Journey

Finding the right dose of pancreatic enzymes can feel overwhelming at first, but with patience and support, it becomes second nature. Remember, the goal is to improve your quality of life by reducing symptoms and ensuring proper nutrient absorption.

For more information or personalised advice, feel free to reach out to our team. Kylie  is specialised in Creon prescribing and provides teaching on this topic to medical and dietitian colleagues around New Zealand.

‍