Selecting Products
Which Enzymes?
Dosing Guidelines
Mixing Suggestions
Interactions w/ other things
What to Expect Starting
General Trends
At School
Getting Started Step-by-Step
Enzyme Safety

Sensory Integration
Digestive Disorders
Food Sensitivities

Leaky Gut
Bacteria / Yeast

PDD/Autism Spectrum

Autoimmune / Neuro Cond.
Heart/ Vascular Health
Sports Medicine

This independent site is for education and information about digestive enzymes. There is a large need to provide practical and general information on enzyme therapy for a wide range of uses.

Enzymes have been around a very long time. Hopefully this site will help reduce the learning curve.

Ideas, comments, and questions are welcome.

Site Information




Dosing Guidelines

last updated 4.29.06

How Much Enzyme to Give

For general digestion, enzymes are dosed by the quantity and type of food, not by age or weight. You may need to experiment a little and see how much of a particular enzyme product is needed for specific foods for a particular individual. Check the serving size or dose given on the label and use that as a guide. Then watch the reaction and adjust the dose accordingly. Since different products can have vastly different activities, you may need to take four to six capsules of one product to equal the effectiveness of one capsule of another product.

The goal is to give an amount of enzymes that can break down all the food eaten in the 60 to 90 minutes the food and enzymes are together in the stomach. Although the enzymes will continue to break down foods as the contents of the stomach move into the intestines, any casein, gluten, or other foods not adequately broken down in the stomach and passed into the small intestine is a candidate for ‘peptide’ production (or other insufficiently digested food particle which could cause a food allergy or intolerance reaction) and absorption in the gut.
see Guide to Selecting, Comparing and Buying Enzymes
see Which Enzymes with Which Foods

As a damaged or leaky gut heals, you may need fewer enzymes than in the beginning. Always check the label and manufacturer’s recommendation for any particular product you are interested in. To minimize adjustment effects, start with a partial dose in the very beginning and work up to a full dose.

Timing - When to Give Enzymes

Giving enzymes to break down food
Enzymes work on contact with the food or substrate with the appropriate bonds. So the enzymes must be in physical contact with the food or substance in order to work. Enzymes usually come in capsules you can open or swallow, or as enterically coated tablets you cannot open. The capsules are preferable because they can either dissolve in the stomach releasing the enzymes, or you can open the capsules and mix the enzymes with any food or drink and take at the beginning of a meal. This allows the enzymes to be breaking down food in the stomach before it passes in into the small intestine.

Enterically coated tablets do not work in the stomach. They don't start until they reach the intestines and the coating dissolved away.

Capsules are either vegetable-based (veggie) or gelatin-based. Both types will dissolve in your gut. Some people find that they get much better results from veggie capsules if they wait about 20-30 minutes to allow more time for the veggie capsules to dissolve. This has not been an issue with gelatin capsules because they dissolve right away at body temperature, whereas the veggie capsules may not. Other people find they get best results by opening the capsules and mixing the enzymes with the food before eating. You may want to experiment a little to see which method gives you best results. Some parents who do not see good improvement with enzymes find they get significantly better results when opening the capsules and mixing the enzymes with food. For others, this does not make a difference.

Some people find they get much better results if they take enzymes will all food and drink especially in the beginning. This may have to do with facilitating an injured gut to heal. As the gut heals and the immune system strengthens, less enzymes may be needed over time and you would not need to be so picky about the timine, or need them with all foods. Consider that the gastrointestinal system is a dynamic place. It starts repairing any damage immediately. The estimated time for gut healing is typically between three and six months for 'average' gut injury, going up to 12-18 months for 'severe' cases.
see Leaky Gut

Be sure to check the dosing on the package label. Some products list one capsule as a 'serving' and other list 2, 3, 4 or more capsules as a serving. Consider serving size when comparing cost and enzyme activities as well. A product may require 4 capsules to achieve the level of enzyme activity listed. Different products have different efficacy as well. You may find that one capsule of one enzyme product is as effective as 3 or more capsules of another product.

Check the number of capsules in the enzyme package. Enzymes usually comes in amounts of 30, 60, 90, 120 or 180. A few companies offer samples sizes of their enzyme products.

Giving enzymes for some reason other than food digestion
For getting benefits of enzymes other than digestion, you will need to check on the dosing with your health practitioner or the manufacturer. In general, taking proteases between meals may be effective for non-digestive health benefits. Examples would be gut healing, blood cleansing, detoxification, bruise healing, reducing pain from arthritis, fibromyalgia, or migraines, etc. For specific cases of treating an autoimmune condition, you would need to research each particular area and find out the dosing and enzyme mix needed for each situation. Certain mixtures convey benefits where giving the enzymes separately do not. It can take between a few days and a few weeks or months to start feeling better. For sports injuries or similar situations, taking more proteases per day for several days seems effective, in general. For colds and general illness, taking a strong protease product such as Purify or Peptizyde several times a day, 3-4 capsules at a time, can significantly decrease both the duration of the illness and the intensity of illness.
see Migraines/Pain
see any of the other conditions mentioned under Specific Conditions

If you are trying to heal an injured gut, or leaky gut, some people see better results if they give enzymes with all foods all the time (meals, snacks, liquids, supplements)- probably helps with gut healing and overall digestion of all foods. Then as gut healing progresses, less enzymes may be needed. Many people find after time they do not need as many enzymes, only give them occassionally, or only with main meals. The gut is a dynamic place, so healing (or injury) begins immediately. Usual time frame for gut healing is 3-6 months for 'average' injury, and up to 12-18 months for 'severe' cases.

Mixing Suggestions

Enzymes will work when they are in contact with the appropriate substance. Usually, as long as you get the enzymes in the stomach, it doesn't really matter what you mix it with or how this is achieved. Here is a list of ideas:
see Mixing Suggestions

There are few interactions between enzymes and other supplements or medications. But if you are on a medication, particularly a time-released one, you may want to consult your doctor or pharmacist about any possible interaction for your health situation, just to be sure. Usually enzymes make any supplements or medications more effective because of enhanced absorption and gut healing. Enzymes can improve absorption and uptake of anything consumed: foods including special diet foods, supplements, and medications.
see Interactions

A synergistic effect has been found between enzymes, particularly proteases, and antibiotics and antifungals (medications for killing yeast).
see Enzyme/Bacteria Research
see Enzyme/Yeast Research
see Bacteria Overgrowth Conditions
see Yeast (Candida) Overgrowth Conditions

Suggested Dosing When Starting Enzymes
general guidelines

Keep in mind that there isn't just one right way only to do this, and many schemes work just fine. Most relatively average people with pretty good health do fine starting by taking enzymes according to the recommended dosing given on the label of their chosen enzyme product. They use enzymes for general digestion and overall health maintenance.

However, those with health situations they are trying to improve or correct - a therapeutic use of enzymes - may find this doesn't work or causes too much discomfort in the beginning. Following are the strategies that seem to provide the easiest adjustment for the most people in these situations of more serious gut injury.

If you have an injured gut, really poor digestion, bad bacteria or yeast problem, it seems to help to pick a broad-spectrum product not high in proteases and then a separate high protease product. The reason is that proteases might cause some irritation to seriously injured tissues, so a 'gentler' approach works better. The proteases are not necessarily harming the injured tissue, just causing irritation. Think of when you may have skinned your knee or other similar injury. The wounded area is hurting, maybe bleeding. Maybe there is dirt in the area or the beginning of an infection. You need to clean the wound and apply disinfectant. This is needed to help the wound heal, but it does sting and hurt during the cleaning out processes. This is similar to what proteases may be doing. They clean out wounds, clean out infections, yet in the process may cause some irritation.

Proteases may do other tasks besides food breakdown, which also brings the potential for more adjustment effects. Proteases can also have an impact on bad bacteria, yeast, parasites, and viruses so they can contribute to greater die-off reactions. Proteases also more directly heal tissue and clean out wounds. Although all these healing activities are beneficial, they can also be accompanied by more adjustments which eventually go away anywhere from 1 day to 4 weeks or a little more depending entirely upon the enzyme product and the severity of your particular problem. Some people see no or very minimal adjustments while others see more.

Starting with the broad-spectrum product allows some gut healing to occur and then introduce the strong protease product at a later date. This way more effective doses of other non-protease enzymes can be given. It also helps the body to get used to improved food breakdown and nutrient absorption before the strong proteases come into play.

A good example is the combination of Peptizyde or GlutenEase with either HN-Zyme Prime or Lacto. If fruit-derived enzymes are not tolerated, then AFP Peptizyde or GlutenEase plus Lacto would work well. Look for enzymes in the general categories, and also which do not contain ingreidents which may be a problem for you.

Starting with the broad-spectrum product, try about 1/2 capsule at two meals the first day, then all meals the next day...then one full capsule at each meal the third day and fourth. If this is tolerated okay, then add any other enzyme products in, starting gradually in the same manner. With the strong protease, if there is excessive hyperness or die-off the first day at 1/2 capsule, stay at that level of dosing until the person adjusts, then increase to the next level. On rare occassions, it worked better to increase by 1/4 capsule of strong protease at a time. You may want to allow 1-3 weeks for preliminary gut healing to occur before adding strong proteases. Again, there is no exact way to go about this.

The Great Low-n-Slow Method
specific guidelines

Start with broad-spectrum product. A 'broad-spectrum' enzyme product is one that has some of several different enzymes intended to help across the board for general digestion of meals containing several food groups. Some good broad-spectrum products are:

  • Digest Gold (Enzymedica)
  • HN-Zyme Prime (Houston Nutraceuticals)
  • Vital-zyme Forte (Klaire Labs)
  • Vital-zyme Complete (Klaire Labs)
  • Elite-zyme Ultra (Thropps Nutrition)

If the broad-spectrum product leads to too much discomfort,
_. . .0r you just don't know what to try,
___. . . and have very bad gut problems, try one of these:

  • V-gest (previously was called Carbo, by Enzymedica)
  • Lacto (by Enzymedica) - particularly good for dairy intolerance
  • Zyme Prime (by Houston Nutraceuticals, not HN-Zyme Prime)

V-gest (formerly called Carbo) has good activity as a broad-spectrum product, but substantially lower proteases that other broad-spectrum enzyme products (about 15,000 HUT). You can dose the proteases separately without giving up the enzyme activity of all the other enzymes. V-gest is often tolerated where others are not, particularly in the beginning. V-gest has no 'fruity' enzymes (papain, bromelain, actinidin, ficin), fillers or other ingredients which eliminates those as possible sources of not tolerating the enzyme product. It is a good one for highly sensitive people as a starter product. Especially if you aren't sure if you react to the fruity enzymes or particular added ingredients.

Lacto has around 25,000 HUT proteases and more enzymes for dairy digestion. If dairy is a concern, this would be a good low-protease product to consider. Lacto does not have papain, bromelain, or actinidin enzymes which can cause problems in sensitive individuals. It contains no fillers or extra ingredients which eliminates another potential hurdle in the beginning. Lacto contains enzymes to help with all aspects of dairy - the casein/proteins, the lactose/sugar, and the fat portion of dairy. This is a 'best bet' product to consider when starting particular with sensitive guts or moderate to serious gut injury. You can always switch to another product after initial gut healing has progressed if you choose. I will use Lacto in the following discussion to represent the broad-spectrum enzyme product.

Start with 1/2 capsule of Lacto (or other broad-spectrum product you tolerate and are going with first) at a couple meals for a couple days. Then increase to 1/2 capsule with all meals and bigger snacks. You can do all snacks if you want to. Do this for a couple days. Then increase to 1 full capsule at a couple meals for a couple days with 1/2 capsule at other eating times. Then increase to a 1 full capsule at all meals and all snacks.

If at any time, you have too much die-off or are intolerably uncomfortable, stay at that enzyme level for a few days until it levels off before increasing the dose again. If you increase the enzyme dose, and find the adjustments too uncomfortable, decrease the dose again and stay at the reduced dose for another day or two before trying to increase it again. There isn't any one right or wrong way to do this and it will likely depend on what adjustments/healing your body is going through as well as your own personal tolerance level for how much discomfort you are willing to put up with.

Please note that it is just as common to have no adjustment effects or discomfort at all as often as it is to have adjustment effects. So if you just feel great the entire time, that's wonderful and you aren't doing anything wrong.

If you are having adjustment effects, do any detox measures during this time you find helpful: antioxidants, epsom salts, milk thistle, activated charcoal, bottled water, whatever seems to help. You don't have to do all these things, it is just a list of ideas to consider.

After you get up to 1 full capsule of the broad-spectrum enzyme product, add in a strong protease product. Some good ones are:

  • Glutenzyme (Biocare in England)
  • GlutenEase (, byEnzymedica)
  • ViraStop (Enzymedica, not just for viruses; previously was called Purify)
  • Peptizyde or AFP Peptizyde (Houston Nutraceuticals)
  • Peptidase Complete (Kirkman Labs)

Add the strong protease enzyme at meals with the broad-spectrum enzyme at 1/2 capsule at a couple meals for a couple days. If all goes well, then increase to 1/2 capsule at all meals and large snacks for a couple days. You can add it at all snacks if you like. Then increase to 1 capsule at a couple meals for a couple days with 1/2 capsule at other eating times. Then increase to 1 capsule at all meals and large snacks.

Again, if you have too much die-off or are intolerably uncomfortable, hold at that enzyme level for a few days allowing your body time to adjust and process out any junk in the system. Healing takes some patience and time, although enzymes are relatively efficient.

Strong proteases are much more likely to cause die-off of pathogens, so if you see more die-off or other adjustments with the strong protease product than before with the broad-spectrum product, this is common and to be expected. Strong proteases do more direct healing work, so the adjustments might be more noticeable. This is the advantage of dosing proteases separately. You can dose the proteases more or less as you need them without giving up all the other broad-spectrum enzymes at the same time.

After you are adjusted up to 1 capsule of strong protease product and 1 capusle of broad-spectrum enzyme per meal and major snacks, then start the between-meal enzyme program, if you are planning on one. Feel free to try going up to 2 of each type of enzyme product at each meals. Or 6 or 12. There isn't an upper limit and some people may see more benefit in higher doses especially in the beginning. Products with lesser enzyme activity or less effectiveness may need more capsules per meal in order to equal 1 capsule of the higher quality brands.

If you are using V-gest, Lacto, or Zyme Prime as your broad-spectrum product and are now up to 1 full capsule of proteases with meals too, you can consider switching from these low-protease products to a broad-spectrum enzyme product with higher amounts of proteases (Digest Gold, Elite-zyme Ultra, etc). This is simply for convenience and to get more proteases in at meals. A lower-protease broad-spectrum product is suggested in the very beginning because it allows a more gentle, and often tolerated, start. Once the gut is healed enough to tolerate more proteases, you can try a different higher protease broad-spectrum product if you want. Even if you switch to a higher protease enzyme product, it is good for healing to keep giving the strong protease product if you can.

Additional Guidelines for Yeast/Candida Control

If you have a yeast/Candida problem, or think you might, and want to try digestion enzymes, here is the recommended suggesstions that typically prove successful. Starting enzymes and a good yeast program usually helps many of these things drop off or at least greatly reduced in severity.

Candida usually takes a total program approach: certain enzymes, plus some diet changes, plus some yeast killer, plus detox aids, plus a good probiotic, plus stress management...a total program works much better than any of these alone. Yeast can be tough.

Many yeast control products include the recommendation to stay on a sugar-reduced diet for a couple weeksat least and keep up the yeast-control program for at least 2 months.

Follow the Great Low-n-Slow Method above. After you are successfully at 1 capsule of protease enzyme product and 1 capsule of broad-spectrum product per meal/eating time, continue as follows.

At this point, you can start whatever probiotic you have chosen, starting at a reduced amount and working up to the final dose over a couple days or more. If you don't have a probiotic, it would be good to look into one because the good microbes help fill the vacancies left by the bad guys killed off. Lots of probiotics help crowd out the bad guys too.
see The Probiotic Short Course

The probiotics and enzymes plus any yeast-killer all seem to have a synergistic effect on yeast and work well together. However, if you start them all at the same time, the die-off can be majorly overwhelming, so this gradual stepping was started just to make it
more tolerable (particularly for kids who don't really understand why they are feeling bad).

You can take probiotics and enzymes in the same day definitely. Many probiotics can be taken at the same time as enzymes. Some probiotics aren't as 'stable' with enzymes so some people find that some probiotics at better for them if taken apart from enzymes. You can take enzymes at the beginning of the meal and probiotics at the end of the meal, in-between meals, or at bedtime. Just try it taking the enzymes and probiotics both ways and see which works out better for you.

After you get the probiotic to an appropriate dose and all is tolerated, add in the yeast-targeting enzyme between meals. Examples of products containing enzymes just for yeast control are:

  • Candidase (Enzymedica) – contains cellulase and proteases
  • Candex (Pure Essence) – company has several formulations of this product. The older version contained cellulase plus probiotics. The newer version in most locations in the US has an assortment of just enzymes for fibrous foods but no proteases. A version sold in England has the fibrous enzymes and include proteases. Besure to check which version you are getting.
  • Candizyme (Renew Life) - similar to the Candex with proteases.

Notes: Some enzyme product have been seen to be very effective on yeast even though they are not specifically labeled for yeast control. However, the enzymes in the products just happen to be higher amounts of fiber digesting enzymes which help with yeast control. A few products in this category are:

  • V-Gest (Enzymedica)
  • No-Fenol (Houston)
  • Phenol Assist (Kirkman Labs)
  • Carb-Digest with Isogest™ (Kirkman Labs)

Yeast control enzymes may be helpful with conditions such as ulcerative colitis, Crohn's, celiac, irritable bowel syndrome, irritable bowel disease, and other conditions caused by bacteria, yeast, and inflammation in the gut. It helps to keep the roughage down to not irritate the gut lining, as well as fight yeast directly.

The yeast-targeting enzyme products have very different formulations. If one doesn't work out for you, do try one of the other formulations before giving up altogether. You may find rotating or combining more than one yeast-targeting product is also helpful.

Start the yeast-targeting enzyme between meals at 1/4 a capsule. This one starts lower because it has a record of being particularly 'potent' on yeast. Increase slowly to 1/2 capsule and then 1 full capsule between meals 2-3 times a day. Mid-morning, mid-afternoon, and at bedtime seem to work well.

When you get up to 1 capsule three times a day (or whatever amount works best for you), then add in a yeast killer such as oregano (oregacyn is good), grapefruit seed extract, or whatever other yeast killer you are using between meals WITH the yeast-targeting enzyme. Again, this has a history of being highly synergistic and effective on yeast so you may see an increase in die-off symptoms.

So in summary,

  1. gradually start a broad-spectrum enzyme product at meals until you get to 1 capsule at each meal
  2. gradually add in a strong protease enzyme product at meals until you get to 1 capsule at each meal
  3. gradually add in a probiotic between meals (or at the end of meals) until you get to the recommended dosage. If you are already taking a probiotic, skip this part.
  4. gradually add in a yeast-targeting enzyme product between meals until you reach a comfortable level or 1 capsule 3 times a day.
  5. gradually add in a yeast killer between meals with the yeast-targeting enzyme product until you reach the desired level

The entire process may take a few weeks. If you want to go faster, certainly it is fine to try it - go as quickly as you like. But this is a more conservative method designed to help make die-off tolerable in more serious cases when it is more dreadful, or the person is very sensitive.

I tend to favor doing more enzymes to help fight pathogens as they seem very safe and 'natural' and help as well as anything else. You can go up to many enzymes between meals if you want. Adding in a strong protease product (such as Purify or Peptizyde) with the yeast-killer ( No-Fenol, Candidase or other) between meals would be something to consider. Proteases are thought to help breakdown the debris and carry it off so it is less likely to provoke die-off symptoms and discomfort. A general rule of thumb is to add 2 capsules of strong protease enzyme for each capsule of yeast-targeting enzymes.

Additional Guidelines for Systemic Healing: pain, (auto)immune system support, arthritis, circulatory problems, etc.

Follow The Great Low-n-Slow Method above. It is suggested to go ahead and start a broad-spectrum enzyme with meals at least to help minimize any insufficiently digested food which can very often be part of the problem even if you aren't aware of any digesstive or food problems.

After you are successfully at 1 capsule of protease enzyme product and 1 capsule of broad-spectrum product per meal/eating time, continue as follows.

Start adding in capsules of the strong protease between meals. Basically, as many as you can - the more you take the quicker you heal. Aim for 1 capsule three times a day between meals, then 2 capsules 3 times a day between meals, and then 4 or more until you get at a level you can manage. There really isn't an upper limit. The therapuetic level is usually 9-12 capsules between meals as a minimum of a good plant derived enzyme products. Products like Wobenzyme often say to use much more going as high as 45-60 tablets a day. Examples of enzymes specifically for other non-food uses are:

  • ViraStop (Enzymedica) - for general immune system support and rocks on viral problems
  • Repair by Enzymedica – contains proteases, amylase, and lipase; features bromelain for reducing inflammation
  • MucoStop (Enzymedica) - break down mucous and reduce histamine
  • Natto-K (Enzymedica) - fibrinolytic activity (breaks down fibrin) and antioxidant activity
  • Vitalzym (World Nutrition)
  • Wobenzym

Additional Guidelines for Special Diets or Adding in Previously Eliminated Foods

Follow the Great Low-n-Slow Method above. After you are successfully at 1 capsule of protease enzyme product and 1 capsule of broad-spectrum product per meal/eating time, continue as follows.

Special Note for GFCF diets (casein-free/gluten-free): If you are wanting to supplement a GFCF diet, or use enzymes instead of a GFCF diet, the only product proven to successfully replace a GFCF diet consistently is Peptizyde by Houston Nutraceuticals. Many families have used this product instead of a GFCF diet for nearly 4 years. Is is an excellent addition to a GFCF diet as well.

It is recommended to get used to the enzymes first to ensure the enzyme product itself is well tolerated. If you want to use enzymes while continuing with a special diet you needn't do anything else. 'Good' enzyme products generally bring another level of improvement to any special diet because they help you digest your special diet food and do the other benefitical activities enzymes are known for.

To reintroduce previously eliminated food, select one food at a time and test it. Try to test a food in a 'pure' form so you can tell accurately if the food can be eaten with enzymes. For example, to test dairy, try whole milk because low fat milks may have hidden artificial preservatives that may cause a reaction. Test a piece of cheese instead of a cheese pizza so the bread, tomato paste, meats, and other things in the pizza aren't clouding results. After a few days and tests, you can go on to the next food.

This gradual deliberate method is only to help keep things straight. If you have pizza with Peptizyde or a casserole made with cream and cheese with Lacto and all goes well, GREAT! Whatever works. But if you have pizza with an enzyme for dairy and have an adverse reaction, don't assume it is the might be one of the other ingredients; and then you will need to test one ingredient at a time with the enzyme to see what is actually tolerated and what is not.

Please note that even with enzymes, there may be some foods you still can't tolerate. But usually with enzymes, a person no longer has to eliminate 48 different foods, only 3 or 4. So it is still a vast improvement overall.

If you are taking many supplements and medications, you may find many of these are no longer necessary or you can the same results with a reduced dose. Enzymes improve absorption of everything consumed: food, including special diet foods, supplements, and medications.

It is common for some people taking 20-40 different supplements to now only need 4-5, which saves substantially on cost and hassle. The reason is you are getting more nutrition from your food with enzymes, in a whole food form.

If you are not able to resume eating previously eliminated foods and you want to, continue taking enzymes for 4-8 more weeks to allow more time for gut healing. Then try the foods again. Testing foods to see if they can be put back into the diet is refered to as challenging the food or challenging the diet.

Note: Digestive enzymes are awesome on actual food, but many artificial additives are not real food or nutrition from the body's point of view. So enzymes may not be effective on those. You may still need to avoid artificial colorings, flavorings, preservatives and other additives. Nitrites and sulfites can be added or occur naturally in foods. Sometimes a person has an intolerance to these chemicals which enzymes might not help. If you notice you can add back many previously omitted foods except a few, try to find out if there is a common chemical in these problem foods. For example, if you need to still avoid tomatoes, bananas, and oranges with enzymes but all other foods are can be eaten, consider an amine intolerance.
see Food Sensitivities

Case study: low-n-slow enzyme dosing

This study uses pancreatic enzymes and tells how a child who had vomiting initially was put on a gradual dosing from a very small amount increasing slowly to the full amount needed. I thought it was a good testiment to gradual ramping up of enzymes if the person is very sensitive and has trouble taking enzymes in the very beginning.

Desensitization to pancreatic enzyme intolerance in a child with
cystic fibrosis.

Chamarthy LM, Reinstein LJ, Schnapf B, Good RA, Bahna SL. Pediatrics. 1998 Jul;102(1):e13.
PMID: 9651465 [PubMed - indexed for MEDLINE]

Division of Allergy/Immunology, Department of Pediatrics, University
of South Florida, Tampa, Florida, USA.

OBJECTIVE: Pancreatic enzyme is essential in the treatment of cystic fibrosis (CF), but intolerance to it occasionally occurs. We encountered a child who was intolerant to multiple commercially available preparations of pancreatic enzymes and, hence, desensitization was attempted, with success.

CASE PRESENTATION: A 33- month-old girl was diagnosed with CF at 6 months of age. Initially, she was started on Pancrease MT 16, which was subsequently discontinued because fecal fat studies were normal and she seemed to do well on Nutramigen and vitamin supplements. At 29 months of age, she developed diarrhea with bulky stools and weight loss. A fecal fat 72-hour study revealed a coefficient of absorption of 50%. She was treated with Pancrease MT 16, but had consistent vomiting 1 to 2 hours after administration of enzymes. The vomiting occurred on switching to different pancreatic enzymes preparations, ie, Creon 10, Viokase, and Pancrease MT 16. Vomiting occurred even with small doses of enzymes disguised in food. She had no history suggestive of gastroesophageal reflux, peptic ulcer, or pork allergy, and no vomiting on days when enzymes were not given. This was suggestive of type I hypersensitivity reaction. Pancreatic enzymes were discontinued, and she was given a low-fat, high-carbohydrate diet with satisfactory weight gain. METHODS: Double-blind, placebo- controlled titrated oral challenges with pancreatic enzymes resulted in definite vomiting within 1 to 1.5 hours after challenges with Viokase and Pancrease MT 16, but not with placebo. Rush oral desensitization with Viokase solution was attempted, starting with 5 mg, and the dose was doubled every 20 minutes, aiming to reach a cumulative dose of 700 mg. However, the child vomited when a cumulative dose of 315 mg was reached. Another trial of slower desensitization was done using Pancrease MT 16 (1 capsule: 16 000 U of lipase, 48 000 U of amylase, and 48 000 U of protease), starting with 1/4 capsule per day, with increments of 1/4 capsule every 3 days, until an entire capsule was reached by day 10, then increased by approximately 1/2 capsule every 4 days until reaching the therapeutic dose of 1 capsule with each meal by day 25.

RESULTS: The patient tolerated this fairly well and has been on this treatment and regular diet for >1 year, without any adverse reaction. This illustrates a rare case of gastrointestinal adverse reaction to pancreatic enzymes that was treated successfully with desensitization.

CONCLUSION: Pancreatic enzyme intolerance, although rare, would be a major problem in the management of patients with CF. Hence, desensitization would be essential and may be accomplished successfully using the protocol described in this report.

Dosing an Enzyme Product Designed for Practitioners

There are few lines of enzyme products designed for health practitioners. These are generally not retail lines accesssible by the general public. The feeling is that if you have a health issue serious enough you are considering very high doses of enzymes, then having some input with a health practitioner may be helpful. Or a company may just choose to market to health practioners instead of following a retail business structure. The practitioner's line of enzyme products are usually highr in potency.

Because of this higher potency, it may be very helpful to start at a lower dose and slowly ramp up to the recommended dose. Instead of starting at a 1/2, start at around a 1/4 capsule. Basically following the Low-n-Slow Method, but decrease the amounts by half.

Start at 1/4 capsule for a day, then increase to 1/2 capsule for a couple days, then up to 1 capsule, and continue up gradually like this until you get to the rcommended dose. It's typical to 'feel' some effects from enzymes or anything else that is working. However, if you are so uncomfortable it's stressing your life, back down on the dose a bit and ramp up gradually.

see Resources to Find Practitioners or Specialists Supporting Enzyme Therapy