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Your doctor has prescribed pancreatic enzyme replacement therapy (PERT) for your exocrine pancreatic insufficiency (EPI). But you can’t just take a daily pill and that’s it. There are various steps and strategies involved. You may wonder how you are going to manage remembering how and when to take this medication. 

 As with anything new, this can feel overwhelming at first. But PERT can be mastered and can make a big difference in your health, improving the ability of your body to digest and gather nutrients from your food. Keep the following tips in mind to help make the most of your PERT treatment.

Why Is PERT Important?

PERT is the main treatment for exocrine pancreatic insufficiency (EPI). If you have EPI, your body isn’t digesting food as it should. PERT medications provide the digestive enzymes your pancreas isn’t making – chemicals that let your body digest food and get nutrients from it. 

If your body can’t absorb these nutrients, you’re at risk of malnutrition. You could lose weight and get illnesses like osteoporosis (thinning bones) or anemia (not enough red blood cells). 

Besides preventing these problems, PERT helps lessen or do away with the digestive symptoms you may have due to your lack of pancreatic enzymes, such as stomach pain and diarrhea.

But for PERT to work, it has to be taken the right way. 

How Much PERT Do I Need? 

PERT comes in different doses and formulas that you take by mouth (usually as capsules). Dosage amounts are listed in lipase units. (Lipase is an enzyme that helps your body digest fats.) The amount you take can be based on your body weight or how much fat you eat, although your doctor also may use standard dosing guidelines.

Most adults starting PERT take two to three capsules (20,000 to 25,000 lipase units each) per regular-sized meal, and one to two for snacks and small meals. 

Once you see how your body does with the medication, your doctor may want you to take a different dosage. The level of pancreatic enzyme insufficiency can vary from person to person. The same is true for how much PERT you need. 

How and When Do I Take PERT?

PERT is taken with food – usually your first bite of a meal or snack 

That’s because you need the PERT enzymes to get into your small intestine right away, to help you start digesting your food. 

Depending how big your meal is and how long it takes to eat it  – especially if it’s longer than a half-hour – you may need to take more PERT capsules. You can take these during your meal, at the end of it, or both. If you are having a multiple-course meal, take enzymes with each course. 

You need to take your medication with cold or room-temperature liquids – never anything hot, because that can cause the pills to dissolve in your mouth, not inside your intestine. This can make the medication not work. 

If your meal is all liquid – such as a meal replacement shake or smoothie – you still need to take PERT. 

What if I Can’t Swallow the Big PERT Capsules?

The bigger doses of PERT come in larger capsules. Some people can find them hard to swallow. You can ask your doctor if you can take smaller capsules, which have lower doses. (This means, of course, that you’ll have to take more pills to arrive at the same dose.)

 Another strategy – which is also helpful for small children and infants who can’t swallow pills – is to break open a PERT capsule and gently stir its contents into a small amount of softer food you can eat with a spoon. Experts recommend using acidic foods for this, such as:

  • Applesauce
  • Gelatin
  • Yogurt
  • Bananas (mashed)
  •  Puréed fruit or vegetables (such as in baby food servings of apricots and sweet potatoes) 

Take care not to chew any of the bits of enzymes. When done eating, drink something to help wash down any lingering bits of enzyme that might be stuck in your mouth, lips, or teeth. They could lead to sores if they are left there.

When Should I Not Take PERT?

Some foods are OK to have without PERT. These include:

Very small amounts of food (like a single cookie or piece of chocolate) 

  • Fruit juice
  • Fresh or dried fruit (by itself) 
  • Drinks, such as tea or coffee, where you only have a small amount of milk or creamer 

Also be careful not to take PERT on an empty stomach. 

What Are Common Side Effects From PERT? 

PERT can cause side effects, which usually go away after your body adjusts to the treatment. These include: 

  • Constipation
  • Diarrhea
  • Nausea
  • Stomach pain or discomfort 

If these symptoms continue and bother you, contact your doctor – especially if your diarrhea is serious. You may need to adjust your medication dosage. 

You also may be able to avoid some side effects, such as nausea, by changing PERT brands. That’s because the capsule coating materials are different for each manufacturer. Your body may respond better to one type of coating than another. 

Taking too much PERT can lead to a serious side effect – a condition called fibrosing colonopathy. The condition can cause belly pain, swelling, vomiting, and constipation. Usually it happens only in people who have taken very large amounts of PERT (such as 408,000 units per meal for a 150-pound person – more than four times a standard dose of 100,000 units).

Why Isn’t PERT Working for Me? 

If your EPI symptoms are continuing, you may need a higher PERT dose. See if your doctor is OK with you adding to your doses on your own between checkups, or if you need to call before making a change to your therapy.

For example, fatty foods can be tough for some people to digest, resulting in unpleasant symptoms (such as loose, strong-smelling bowel movements). If you have this problem, you may need more PERT when you eat such foods. 

Other possible remedies that can help boost how effective PERT is include:

  • Eating a healthy, high-calorie diet (especially if you are underweight)
  • Consuming more fat, rather than trying to cut it, since fat is needed to digest many important vitamins – but choose healthy fats from plant sources or fatty fish
  • Increasing your intake of vegetables, fruits, whole grains, and healthy proteins 
  • Eating smaller meals more often, rather than two or three big meals
  • Cutting out alcohol
  • Stopping smoking 

Your doctor also may want you to take antacids, vitamins, or other supplements in addition to PERT.

Other reasons PERT may not work properly:

  • Heat exposure. Be sure to store your medication in a relatively cool spot. If it gets too hot (above 77 F), it will not work. 
  • Expiration. Don’t use PERT after it has expired, as the ingredients will stop working.
  • Taking them with antacids. Don’t take PERT at the same time as antacids made with calcium or magnesium, like Tums or Rolaids. This makes PERT less effective. 

Can I Take PERT if My Religion Restricts Pork? 

PERT is made using enzymes taken from the pancreas glands of pigs. Some religions don’t allow the consumption of pork. But some religious leaders have issued exceptions for PERT, since it’s a necessary medication and there are no alternatives. (All pancreatic enzyme replacements on the market today are made from pork.)

If you’re concerned about this, discuss it with your religious faith leaders. 

Some people can’t have meat products because of  allergies or for other health reasons. If this is an issue for you, be sure to discuss it with your doctor. 

What if I Can’t Afford PERT? 

PERT therapy can be costly, especially if you don’t have insurance. If you do have insurance, your provider may pay more for one brand of PERT than another. Your doctor may be able to switch you to the lower-cost version, saving you money.

Manufacturers often have discount plans that can cut the price a good bit. Groups that help people with pancreas conditions, such as the Pancreatic Cancer Action Network, also have information about assistance programs. 

Are OTC Enzyme Supplements OK? 

You may see pancreatic enzymes offered over the counter at health stores or other places. These usually are mostly made from plant enzymes, and have no – or very little – of the lipase, protease, and amylase enzymes the FDA-approved prescription medication has. 

Over-the-counter supplements aren’t regulated by the FDA, so you can’t know for sure what is actually in these pills. It’s a good idea to talk with your doctor before taking supplements like this. 

When Should I Call My Doctor? 

Call your doctor if you have symptoms that show that the medication isn’t working, such as:

  • Extreme fatigue
  • Dizziness
  • Oily stools
  • Unexpected weight loss
  • Serious diarrhea 

If you have EPI, it’s important to stay in regular contact with your doctor and other members of your health team (such as a nutritionist or dietitian). They can help adjust your PERT treatment to best meet your individual health needs – and to keep your EPI symptoms under control. 

Show Sources


American College of Allergy, Asthma, & Immunology: “Meat Allergy.”

American Gastroenterological Association, GI Patient Center, “Exocrine pancreatic insufficiency (EPI).”

Cleveland Clinic: “Exocrine Pancreatic Insufficiency (EPI).”

GI Society, Canadian Society of Intestinal Research: “Pancreatic Exocrine Insufficiency.”

Guts U.K.: “Pancreatic Enzymes & Pancreatic Exocrine Insufficiency.”

Nutrition in Clinical Practice, American Society for Parenteral and Enteral Nutrition: “Management of Exocrine Pancreatic Insufficiency in Children.” 

OncoLink: “Pancreatic Enzyme Replacement Therapy (PERT).”

Pancreatic Cancer Action: “Pancreatic Enzyme Replacement Therapy (PERT.)”

Pancreatic Cancer Action Network: “Tips to Manage the Cost of Pancreatic Enzymes,” “Pancreatic enzymes.”

World Journal of Gastroenterology: “Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency in the 21st century.”