The goals of PERT are to eliminate malabsorption, reduce maldigestion-related symptoms, and prevent malnutrition-related morbidity and mortality. Dosing and frequency of administration can be challenging because different enteric-coated microspheres are not necessarily similar in vivo and there is no clear consensus regarding treatment. The authors’ recommendations can be found in Table 1.

In patients with suspected EPI and a known history of pancreatic disease, treatment with PERTs can be initiated, even in the absence of formal testing. A clear response would provide diagnostic confirmation of EPI and would also be therapeutic. The authors note that PERT should be taken with the first bite of a meal and that addition of extra enzymes during or toward the end of the meal should be considered.

The authors offer several measures to take in the event that the patient has a poor response to PERTs. (Table 2)

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“Since the required FDA approval of PERT in 2010, we now have reliable medications for the treatment of EPI,” the authors write. “However, there is still much confusion among medical practitioners over the best diagnostic approach as well as dosing and administration of PERT,” with different countries having different guidelines. Additionally, there is evidence suggesting that patients are being undertreated with PERT.

Physicians “need to know when to test for EPI and agree on using the same methods for diagnosing EPI,” the authors continue. “Many physicians do not realize the need to have formed stools analyzed and thus, in chronic diarrhea, this may be problematic. Ultimately, what is critical is the early diagnosis and optimization of treatment of EPI.”

Additionally, “there must be optimization of the currently available therapies for EPI.”


1.      Struyvenberg MR, Martin CR, Freedman SD. Practical guide to exocrine pancreatic insufficiency – Breaking the myths. BMC Med. 2017 Feb 10;15(1):29. 

Table 1 – Recommendations for PERT Treatment

• Titrate the dose of PERT to the presumptive degree of PERT.

• Administer PERT with the first bite of a meal and consider adding extra enzymes during or toward the end of the meal.

• Consider using microspheres, possibly adding a rapid release enzyme preparation and/or acid-blockade.

• Adjust the dose to the fat content of the meal.

Table 2 – Strategies for Management of Lack of Response to PERT Treatment

• Increase dosage.

• Check adherence with patient.

• Add acid inhibitor.

• Consider adding enzymes during/toward end of meal.

• Consider microspheres (possibly adding a rapid release enzyme preparation).

• Look for evidence of concurrent gastrointestinal disorder.