Exploring Alternatives to Creon for Pancreatic Enzyme Replacement Therapy

If you’ve been diagnosed with pancreatic cancer, you’ve probably heard about pancreatic enzyme replacement therapy, or PERT.

The reason: Pancreatic cancer often interferes with the body’s ability to produce the digestive enzymes required to absorb nutrients from food, causing unpleasant symptoms including gas, bloating, and weight loss.

“Most individuals with pancreatic cancer can benefit from pancreatic enzymes depending on their stage of disease and treatment history. It’s common to need enzymes after surgery,” explains Meghan Laszlo, an oncology dietitian at Cedars-Sinai in Los Angeles, California. “For these patients, pancreatic enzymes provide critical support, helping the body digest fat and stop weight loss.”

Why Creon?

Creon, derived from porcine (pig) enzymes, is the best-known and most widely prescribed pancreatic enzyme. It’s enteric coated, which prevents the enzymes from being destroyed by stomach acid.

As a Food and Drug Administration (FDA) approved medication, Creon boasts reliable dosing, predictable absorption, and effective management of exocrine pancreatic insufficiency (EPI) symptoms, including gas, diarrhea, and foul-smelling stools. Unfortunately, Creon also comes with a hefty price tag.

“Most insurers cover Creon for patients with pancreatic cancer, but even with coverage, copays can be expensive,” Laszlo says. Some companies may also require prior authorization, which can delay access to treatment.

At full price, Creon can cost up to $11 for one pill, compared to under $1 per pill for the alternatives. If you take two to three capsules with every meal, and you eat three to five times each day (as recommended for people who are losing weight during pancreatic cancer), the cost of PERT can be steep.

Creon Alternatives

Several alternatives to Creon are available, both by prescription and over the counter. Some people may not be able to afford Creon. Others don’t tolerate it well or choose to avoid pig-based products for dietary or religious reasons.

A few popular options include:

• Pancreaze and Zenpep: Like Creon, Pancreaze and Zenpep are porcine-based and enteric-coated, but they tend to be slightly more affordable.
• Fungal-Based Enzymes: Made from fungi, these over-the-counter (OTC) enzyme supplements may appeal to people who are avoiding animal products, or those with dietary or religious restrictions. While they’re cheaper than prescription enzymes, there are no prescription fungal enzymes. “If you’re taking fungal based enzymes, you may need to take more capsules to achieve the recommended dose per meal. This type of enzyme doesn’t need enteric coating,” Laszlo notes.
• Over-the-Counter Supplements: There are many OTC pancreatic enzymes on the market, including porcine and fungal options. The porcine version may not be enterically coated, making them less effective. While they may seem less expensive upfront, you’ll likely need to take more pills to achieve the same dose. Plus, since supplements are not subject to the same rigorous FDA regulations as prescription medications, the quality of these products can vary widely.

A Note About Dosing

No matter which option you choose, it’s important to take PERT capsules at the start of every meal and snack. The range of lipase units needed per gram of fat consumed typically hovers between 500 and 4,000 units per gram of fat consumed (or 25,000 to 80,000 lipase units per meal).

“It’s a wide range because we don’t have a great way of assessing a patient’s need for support,” Laszlo explains. “Some providers start at the top of the range, prescribing higher doses then titrating down based on the patient’s response, while others start low and titrate up.”

The best way to assess efficacy? Monitor your symptoms, Laszlo says. If you experience the following symptoms, you may need to increase your dose of enzymes, or talk to your doctor about trying a different formulation:

• Oily or fatty stools
• Pale orange or yellow stools
• Floating or foul-smelling stools
• Abdominal gas, bloating, pain, or cramping
• Weight loss

The Bottom Line

It’s important to check with your insurance provider about which enzymes are covered—and how much they will pay. If your insurance covers a good portion of the cost, Creon may be the most affordable and effective option.

“Whether you’re interested in taking Creon, or one of the alternatives, it’s important to talk to your healthcare provider about the best options for your specific situation,” Laszlo emphasizes.

No matter which PERT solution you choose, make sure to drink plenty of water while taking enzymes, and if you’re taking more than one capsule per meal, space them out to enhance absorption. Most important: Don’t let cost stand in the way of getting the support you need to digest and absorb nutrients effectively.

“Shop around,” Laszlo says. “Some pharmacies have discounted pricing and there are prescription assistance programs that may you get the medication you need at a price you can afford.”