How to reduce your dose to make your supplies last longer
If your pharmacist can’t get PERT for you and you are waiting for a delivery, take these steps. They will help your existing supply last as long as possible.
Ensure you are taking a proton pump inhibitor. Examples include:
- omeprazole®
- pantoprazole®
- lansoprazole®
Or a (H2)-receptor antagonist. Examples include:
These reduce the acid in your stomach and make the enzymes more efficient. This means a lower PERT dose than your usual dose may be effective if you have a proton pump inhibitor as well. If this does not appear to be effective, they may be stopped.
If you don’t take vitamins and minerals, we recommend that you take a calcium and vitamin D supplement. It should contain 800iu Vitamin D and at least 500mg Calcium. Also, take a multi-vitamin and mineral during this time.
For example:
- Sanatogen A-Z Complete®.
- Centrum Advance®.
- Or, a supermarket’s own A-Z brand. Please ensure they have both vitamins and minerals.
People with CF should stay on their vitamins and minerals. They should discuss any concerns with their CF specialist dietitian.
First step:
- Reduce the dose of PERT by one capsule with any snacks that you take.
- Make the most of the meals you have and spread your PERT out throughout them to optimise digestion
If this is not enough:
- Reduce the dose of PERT by one capsule with each meal and snack, rather than skip whole meal doses.
If this is not enough:
- Reduce the dose of PERT by one capsule with each meal and only have a small piece of fruit as a snack in order that you do not need to take any PERT with snacks.
Please contact your dietitian/nurse specialist or doctor if you are struggling with malabsorption symptoms or are consistently losing weight.
Example meal plans
This is an example of a meal plan with adequate PERT (11 capsules per day):
Meal
|
Example of food consumed
|
Usual PERT dose
|
Breakfast
|
Bowl of cereal with milk and a yoghurt
Orange juice and cup of tea
|
2 x 25,000
|
Snack
|
Cup of tea with 2 x rich tea biscuits
|
1 x 25,000
|
Lunch
|
Tuna sandwich, packet of crisps, banana and a chocolate biscuit
|
3 x 25,000
|
Snack
|
Cup of coffee and a piece of cake
|
1 x 25,000
|
Dinner
|
Cottage pie, vegetables and a scoop of ice cream, Glass of lemonade
|
4 x 2,5000
|
Suggested changes if you do not have adequate PERT, but are nutritionally well (weight stable) or have diabetes. Here the PERT use is reduced to 5 capsules/day:
Meal
|
Example of food consumed
|
PERT dose
|
Explanation
|
Breakfast
|
Bowl of cereal with skimmed milk and a yoghurt, Orange juice and cup of tea
|
1 x 25,000
|
Dose reduced and milk & yoghurt swapped to a low-fat one to reduce any symptoms of insufficient PERT
|
Snack
|
Cup of tea with an apple
|
0
|
Biscuits swapped for an apple so PERT not required
|
Lunch
|
Tuna sandwich, packet of corn crisps (Skips®/Wotsits® /Quavers® etc.), banana and a sugar free jelly.
|
2 x 25,000
|
Dose reduction and reduction in fat content to reduce symptoms
|
Snack
|
Cup of coffee
|
0
|
No snack to reduce dose
|
Dinner
|
Cottage pie (made with lean mince and fat drained off / turkey mince), vegetables and a scoop of sorbet/low fat yoghurt, sugar-free lemonade
|
2 x 25,000
|
Dose reduction and reduction in fat content to reduce symptoms
|
Tips if you are needing to take more capsules of a lower dose as your usual capsules are not available, and are struggling with the number of capsules you need to take:
- If you have some high dose PERT left, take this with you when you go out, and use the low dose capsules when you are at home to reduce the number of capsules you need to take out with you.
- If swallowing the capsules is putting you off your meals take some of them at the end of the meal. For instance, if you need to take 20 capsules with your meals, take 5 at the start, 5 in the middle and 10 at the end.
- Ensure you do not chew or crush the tablets, this will make them less effective and can damage your gums or cause unpleasant mouth ulcers.
Advice for people with diabetes
If your diabetes is controlled by diet or you take Metformin/DPP-4 inhibitors (Gliptins) without any other medication, you do not need to change any of your diabetes management.
If you take insulin or medicines that can cause a hypo/low blood sugar please read the advice below carefully:
If you take less enzymes with your food, you are likely to absorb less starchy carbohydrate from food. Sugar absorption Is not affected by a lack of PERT. This will mean that usual carbohydrate county techniques may be less reliable. Therefore, you may need to reduce the amount of quick acting or mixed insulin you inject to prevent a hypo*.
*A hypo is when your blood glucose level goes below 4mmol/l, typical symptoms include sweating, shaking, blurred vision, confusion, palpitations. Always keep hypo treatment on you. You can find more information on recognising and treating a hypo from your diabetes team or online here. You are only at risk of a hypo if you take medication that lower your blood glucose levels. It is not usually possible to have a hypo if you have diet-controlled diabetes, or diabetes treated with metformin/DPP-4 inhibitors (Gliptins) alone.
Monitor your blood glucose levels regularly: before meals, before bed, if you are feeling unwell, if you feel like you are having a hypo* and before driving. If you are driving long distances, make sure you check your blood glucose levels at least every two hours.
If you have a continuous glucose monitor, ensure you have the hypoglycaemic alarm set. If you are having more hypos than usual, you may need to contact your CF/diabetes team for advice on adjusting your insulin doses.
If you have had a hypo, please make sure you have enough PERT to take with the starchy carbohydrate snack you take to maintain your blood sugars (digestive biscuit/sandwich scone/crumpet etc.)
Speak to your diabetes team for advice on reducing your insulin or medication if you start having hypo’s or need to reduce your PERT dose.
Advice for people taking nutritional supplement drinks
If you take oral nutritional supplements (i.e., Altraplen® Amyes®, Ensure®, Foodlink® Fortisip®, Fresubin®), ask your dietitian if they can be changed to a peptide / semi-elemental preparation (i.e., Vital 1.5kcal®, Survimed OPD 1.5kcal®, Peptisip Energy HP®) as many people can manage these without additional enzymes.
These do not come in a wide range of flavours, but you can add milkshake mixes or coffee syrups to increase the range of flavours. Serve them chilled or freeze them into ice lolly moulds or ice cube trays to give you more options.
Sometimes you may be asked to try individual protein supplements or a fat-free nutritional supplements (Actagain Juce®, Altrajuce®, Ensure Plus Juice®, Fortijuce®, Fresubin Jucy® etc.,), you should sip these slowly to give your gut more time to digest them without PERT. If you have diabetes monitor your blood glucose levels closely when taking these.
If you feel bloated with these, don’t worry – this is a normal effect of taking these without PERT, but if it is affecting your quality of life, please let your dietitian know.
Advice for people taking other medication
Please be aware that other medication you take may be less effective if you are not absorbing. This is particularly important for people who take medications to prevent seizures, the formation of blood clots and the oral contraceptive pill. If you are on the oral contraceptive pill, a secondary form of contraception should be used at this time. Please talk to your doctor.