Principles of Therapy and Classification
Digestive disorders, or maldigestion, most commonly result from functional insufficiency of the gastrointestinal tract. This condition is termed secondary enzymopathy, and replacement therapy serves as the primary treatment modality. In congenital (primary) enzymopathies, strict dietary therapy excluding the intolerant substrate comes to the forefront.
Depending on their composition, all enzyme agents are divided into two major groups:
- Containing bile and gastric mucosal extracts (Panzinorm, Festal, Digestal, Enzistal).
- Bile-free, which include pure pancreatin preparations (Mezim, Creon, Triferment), as well as enzymes of plant and fungal origin (Orazase, Solizym).
Bile-Containing Preparations
These agents exert a comprehensive effect: they not only compensate for deficient secretion but also produce a mild laxative effect, making them well-suited for patients prone to constipation.
- Gastric mucosal extract provides proteolysis via pepsin and cathepsin and contains peptides that stimulate endogenous gastrin production.
- Bile acids emulsify fats, improve the absorption of fat-soluble vitamins, and activate pancreatic lipase.
A prominent representative of this group is Panzinorm. It is a bilayer preparation mimicking the physiology of digestion. Its outer layer dissolves in the stomach (releasing gastric extracts and amino acids), while the inner acid-resistant layer dissolves in the intestine (releasing pancreatin and bile).
Another popular agent is Festal. In addition to enzymes and bile, it contains hemicellulase, which breaks down plant fiber. This facilitates enzyme access to food and reduces flatulence. It is important to remember that bile-containing preparations are contraindicated in severe liver disease (especially with hyperbilirubinemia) and intestinal obstruction.
Monocomponent Preparations (Bile-Free)
The foundation of this group is animal-derived pancreatin obtained from bovine pancreas. It contains amylase, proteases, and lipase.
Key rule: the dosage of pancreatin is always calculated by lipase content and directly depends on the degree of exocrine insufficiency. The daily dose can reach 5–10 g. Preparations (such as Mezim or Triferment) are generally well tolerated and administered before meals.
A special place is occupied by Creon, a microgranulated pancreatin. Its microgranules mix evenly with the food bolus (chyme) in the stomach but dissolve exclusively in the small intestine at pH 5.0 and above. Like other enzymes, Creon is strictly contraindicated in acute pancreatitis.
Fungal and Plant-Derived Enzymes
When animal pancreatin is unsuitable or a specific action is required, alternative agents are used:
- Orazase (from the fungus Aspergillus oryzae). Contains an acid-resistant complex for breaking down proteins and carbohydrates. Activated in the alkaline environment of the intestine. It possesses a unique property: it exerts a spasmolytic effect on intestinal smooth muscle.
- Solizym (from the fungus Penicillium solitum). A narrow-spectrum preparation that hydrolyzes fats exclusively. Normalizes blood lipid levels. A combined form also exists — Somilase (Solizym + $\alpha$-amylase), which additionally breaks down carbohydrates.
- Nigedase (from Nigella damascena seeds). A plant-based preparation with purely lipolytic action. Its activity depends on gastric acidity: in case of low acidity, the preparation is recommended to be taken with gastric juice. Due to the absence of proteases and amylases, nigedase should logically be combined with pancreatin.