Pancreatic enzyme supplementation may cause gastrointestinal distress (including diarrhea, cramping, and nausea) at high doses.27 Additionally, oral ulceration and bleeding have been reported, presumably the result of digestive enzymes contacting the
oral mucosa. Ulcerations may be alleviated by reducing the dose28,29 or by incubating the enzymes in the food for longer periods.28
Alternative sources of pancreatic enzymes have been investigated. Fungal lipase, derived from Aspergillus species, is acid-resistant, so it survives gastric transit but, unfortunately, is deactivated by proteases and bile acids
within the small intestine, making it inferior to traditional supplementation.30,31 Bacterial lipase, derived from Burkholderia plantarii, survives gastric and intestinal transit. It has been proved to correct steatorrhea more effectively than porcine pancreatic
enzyme supplements and requires much lower doses.30,32 Bacterial-derived enzymes may be ideal for treating EPI, but high cost and reduced availability may limit their use.
Dietary modification may improve clinical signs in dogs with EPI. In most cases, trial and error is needed to discern the
appropriate diet for a patient.33 In people with EPI, high-fat diets are used to maximize weight gain.34 This type of diet may be helpful in dogs, but it can worsen diarrhea and may increase the requirement for enzyme supplementation.33 In most cases, a moderate-fat diet is recommended.2 Low-fat diets have not been shown to improve clinical signs over moderate-fat diets.13
Replacing diets rich in long-chain fatty acids with those containing more medium-chain fatty acids, such as Purina Veterinary
Diet EN (Nestlé Purina), also does not seem to improve clinical signs, although this may increase intestinal absorption of
cholesterol and fat-soluble vitamins, which can be decreased in patients with EPI.35 High-fiber diets are generally not recommended because they increase fecal mass, are poorly digestible, and can inhibit
the absorption of other nutrients.33 However, some dogs can show improvement in fecal firmness and a decrease in flatulence and borborygmi when receiving high-fiber
diets.33 Finally, hydrolyzed protein diets have resulted in improved body condition in some dogs with EPI.36
We typically recommend initiating therapy with an easily digestible diet such as Purina Veterinary Diet EN or Iams Veterinary
Formula Intestinal—Low-Residue (Iams). If no response is seen, the dosage of pancreatic enzyme supplementation is usually
adjusted before alternative diets are used. In general, treats are not recommended since it is impractical to administer enzyme
supplementation with each treat to aid in digestion. If clients insist upon giving treats, we recommend waiting until signs
of EPI are well-controlled.
Dogs with EPI should be evaluated regularly. After new treatments are initiated or altered, evaluate patients every two to
four weeks for weight gain and improved body condition. The frequency of evaluation depends on the severity of clinical signs.
Instruct owners to carefully monitor fecal consistency and volume and report any changes. After initial stabilization, patients
with excellent response to therapy may be examined annually or biannually as recommended for healthy adult dogs. Follow-up
monitoring of cTLI concentrations is not indicated since enzyme supplementation and other treatments are not expected to improve
the secretory capacity of the exocrine pancreas.
Figure 2. Percentage of dogs responding to pancreatic enzyme supplementation at recommended dosages. Source: Reference 9.
Dogs with EPI require lifelong treatment. Improvement generally occurs within the first few weeks and stabilizes thereafter.2
Figure 2 shows the response to initial treatment, and Figure 3 shows survival data. About 20% of dogs are euthanized as a direct result of their EPI, usually because of the cost of treatment
or lack of clinical improvement.2 Dogs that respond positively to treatment may experience short relapses, but, fortunately, permanent deterioration rarely
Figure 3. Mean survival time for dogs with EPI based on initial response to therapy. Source: Reference 9.
EPI should be included in the differential list for any dog with small bowel diarrhea. With the advent of more sensitive and
specific testing, EPI has become relatively simple for clinicians to diagnose. Treatment is generally rewarding but can be
expensive and may present a management challenge in certain cases. Given the multitude of concurrent and secondary diseases
that develop, it is also important to remain open to these possible conditions even after EPI has been diagnosed (see the sidebar titled "Canine EPI: Concurrent and secondary diseases").
Jessica A. Morgan, DVM
Lisa E. Moore, DVM, DACVIM
Affiliated Veterinary Specialists
9905 South U.S. Highway 17/92
Maitland, FL 32751