Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 8 Sept 2026Clinical review pending
Saved on this device
!
Escalate
Progressive weight loss, dehydration, new jaundice or a major change in abdominal symptoms needs prompt reassessment of the underlying disease and treatment; do not assume that every problem is simple under-dosing.
Synopsis
Diagnose clinically important pancreatic maldigestion, prescribe and troubleshoot enzyme replacement in lipase units, and demonstrate nutritional recovery while reassessing the underlying pancreatic condition.
Exocrine insufficiency is a clinical maldigestion syndrome: combine symptoms, nutritional assessment and pancreatic function testing where appropriate.
Faecal elastase below 200 micrograms/g is commonly used to support the diagnosis, but no single threshold settles every case; below 100 provides stronger support in a compatible setting.
Use a formed stool for elastase testing; watery diarrhoea can dilute the sample and give a falsely low result.
Key red flags
Continued weight loss or severe nutritional restriction despite an enzyme prescription.
Jaundice, a new focal pain pattern or a previously unexplained pancreatic abnormality.
An allergic reaction or new severe abdominal symptoms while taking pancreatic enzymes.
A plausible pancreatic cause
Establish the pancreatic history and whether a cause has been adequately investigated. Severe necrotizing pancreatitis and established advanced chronic disease create a different pre-test probability from isolated loose stool with no pancreatic history. New unexplained insufficiency requires an assessment for underlying pancreatic disease, including malignancy when suggested, rather than a lifetime repeat prescription without explanation.
Investigation priorities
01
Faecal elastase-1 on a formed sampleFirst step
Obtain a practical indirect measure of pancreatic exocrine function.
Management branches
Worked caseMaking an existing prescription effective
A 46-year-old woman recovering from severe acute pancreatitis has a formed-stool elastase of 64 micrograms/g and persistent greasy stools despite Creon 25,000, one capsule with each meal.
A meal review shows that she takes the capsule with a drink well before food and has no enzymes with snacks. The team changes the regimen to two 25,000-unit capsules per main meal, spread through eating, and one with a snack. She receives practical instructions for intact granules, adequate hydration and the current product cautions, and a dietitian reviews food intake without imposing routine fat restriction.
At the two-week review, stool oiliness has improved but her largest evening meal still produces symptoms. Administration is now correct and no alternative cause is apparent, so the team gradually increases that meal to three capsules, retaining two with smaller meals and one with snacks. Three weeks later her stool frequency has fallen from four to two daily and her weight has increased by 1 kg.
Key medicines
Creon 25,000: 25,000 lipase units per capsuleAdult starting example: two capsules (50,000 lipase units) during each main meal and one (25,000 units) with each snack; distribute capsules through the meal. Titrate gradually to food content and clinical/nutritional response. If swallowing is difficult, open the capsule onto acidic soft food or fluid with pH <5.5, swallow the intact granules immediately and do not retain the mixture. Keep granules uncrushed and unchewed. Review additional causes above 100,000 units per meal or before further escalation when symptoms persist at 10,000 units/kg/day.Contraindicated in hypersensitivity to porcine pancreatin or an excipient; stop treatment and seek urgent assessment for an allergic reaction. Maintain fluid intake and clear residual granules from the mouth. Investigate unusual abdominal symptoms, particularly during high-dose treatment; the fibrosing-colonopathy warning comes principally from cystic-fibrosis patients above 10,000 lipase units/kg/day. Use caution in renal impairment, gout or hyperuricaemia; the product gives no standard renal/hepatic adjustment table. With extreme overdose and raised urate, stop enzymes and rehydrate. Prescribe cautiously during pregnancy; breastfeeding use is permitted at doses maintaining adequate nutrition. Possible HEV contamination of porcine extracts cannot be excluded: immunosuppressed patients on high daily doses should seek care for viral-hepatitis symptoms. Record the product and batch number. Interaction studies have not been undertaken. Keep tightly closed below 25°C and discard after six months from opening.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 8 Sept 2026; clinical approval remains outstanding.