Using Enzymes to

Diagnose and Treat

Diseases

Santos, Patricia Milagros B.

1Nur-10
 Introduction

What is Enzyme?

Enzymes are large biological molecules responsible for the thousands of chemical inter conversions that sustain life. They are
highly selective catalysts, greatly accelerating both the rate and specificity of metabolic reactions, from the digestion of food to
the synthesis of DNA. Most enzymes are proteins, although some catalytic RNA molecules have been identified. Enzymes adopt
a specific three-dimensional structure, and may employ organic and inorganic cofactors to assist in catalysis.

In enzymatic reactions, the molecules at the beginning of the process, called substrates, are converted into different molecules,
called products. Almost all chemical reactions in a biological cell need enzymes in order to occur at rates sufficient for life. Since
enzymes are selective for their substrates and speed up only a few reactions from among many possibilities, the set of enzymes
made in a cell determines which metabolic pathways occur in that cell.

Like all catalysts, enzymes work by lowering the activation energy (Ea‡) for a reaction, thus dramatically increasing the rate of
the reaction. As a result, products are formed faster and reactions reach their equilibrium state more rapidly. Most enzyme
reaction rates are millions of times faster than those of comparable un-catalyzed reactions. As with all catalysts, enzymes are not
consumed by the reactions they catalyze, nor do they alter the equilibrium of these reactions. However, enzymes do differ from
most other catalysts in that they are highly specific for their substrates. Enzymes are known to catalyze about 4,000 biochemical
reactions. A few RNA molecules called ribozymes also catalyze reactions, with an important example being some parts of
the ribosome. Synthetic molecules called artificial enzymes also display enzyme-like catalysis.

Enzyme activity can be affected by other molecules. Inhibitors are molecules that decrease enzyme activity; activators are
molecules that increase activity. Many drugs and poisons are enzyme inhibitors. Activity is also affected
by temperature, pressure, chemical environment (e.g., pH), and the concentration of substrate. Some enzymes are used
commercially, for example, in the synthesis of antibiotics. In addition, some household products use enzymes to speed up
biochemical reactions (e.g., enzymes in biological washing powders break down protein or fat stains on clothes; enzymes in meat
dxtenderizers break down proteins into smaller molecules, making the meat easier to chew).

Etymology and History

As early as the late 17th and early 18th centuries, the digestion of meat by stomach secretions and the conversion
of starch to sugars by plant extracts and saliva were known. However, the mechanism by which this occurred had not been
identified.

In 1833, French chemist Anselme Payen discovered the first enzyme, diastase. A few decades later, when studying
the fermentation of sugar to alcohol by yeast, Louis Pasteur came to the conclusion that this fermentation was catalyzed by a vital
force contained within the yeast cells called "ferments", which were thought to function only within living organisms. He wrote
that "alcoholic fermentation is an act correlated with the life and organization of the yeast cells, not with the death or putrefaction
of the cells."

In 1877, German physiologist Wilhelm Kühne (1837–1900) first used the term enzyme, which comes from Greek ενζυμον, "in
leaven", to describe this process. The word enzyme was used later to refer to nonliving substances such as pepsin, and the
word ferment was used to refer to chemical activity produced by living organisms.

In 1897, Eduard Buchner submitted his first paper on the ability of yeast extracts that lacked any living yeast cells to ferment
sugar. In a series of experiments at the University of Berlin, he found that the sugar was fermented even when there were no
living yeast cells in the mixture. He named the enzyme that brought about the fermentation of sucrose "zymase". In 1907, he
received the Nobel Prize in Chemistry "for his biochemical research and his discovery of cell-free fermentation". Following
Buchner's example, enzymes are usually named according to the reaction they carry out. Typically, to generate the name of an
enzyme, the suffix -ase is added to the name of its substrate (e.g., lactase is the enzyme that cleaves lactose) or the type of
reaction.

Having shown that enzymes could function outside a living cell, the next step was to determine their biochemical nature. Many
early workers noted that enzymatic activity was associated with proteins, but several scientists (such as Nobel laureate Richard
Willstätter) argued that proteins were merely carriers for the true enzymes and that proteins per se were incapable of catalysis.
However, in 1926, James B. Sumner showed that the enzyme urease was a pure protein and crystallized it; Sumner did likewise
for the enzyme catalase in 1937. The conclusion that pure proteins can be enzymes was definitively proved
by Northrop and Stanley, who worked on the digestive enzymes pepsin, trypsin and chymotrypsin. These three scientists were
awarded the 1946 Nobel Prize in Chemistry.
This discovery that enzymes could be crystallized eventually allowed their structures to be solved by x-ray crystallography. This
was first done for lysozyme, an enzyme found in tears, saliva andegg whites that digests the coating of some bacteria; the
structure was solved by a group led by David Chilton Phillips and published in 1965. This high-resolution structure of lysozyme
marked the beginning of the field of structural biology and the effort to understand how enzymes work at an atomic level of
detail.

Enzymes in Diseases

- Medical Application For enzyme therapy. For clinical diagnosis. For diseases of liver, kidney, heart etc. For enzyme deficiency
diseases. For determination of metabolites. Enzyme immuno assay.

- THERAPEUTIC APPLICATION Enzyme Reaction use Amylase Starch hydrolysis Diagestive disorders Collagenase Collagen
hydrolysis Skin ulcers Ficin, Papain, Proteinase Protein hydrolysis Deworming, digestive -disorders,narcotic tissue removal

Bilirubin oxidase Bilirubin hydroxylase hyperbilirubinemia Enzyme Reaction Use Rhodanase Degradation of cyanide Cyanide

Arginase Arginine hydrolysis Cancer

- ENZYMES IN DISEASES Organ Enzymes Diseases Liver ALP, GDH, SGOT, SGPT, Glutamyl Tranferasess, Glutathione S
Tranferases, Viral/toxic hepatitis or cirrhosis, myocardial infraction, jaundice, Heart Creatne Kinases, LDH, AST/ALT,
Myocardial Infraction , skelital muscle disorders. Other diseases Amylases, Aldolases, TG Lipases, CK, ALP, ACP, Choline
Esterases, HMG CO A Reductases, Xanthine Oxidases, GIT disorders, jaundice, bone diseases, rickets,

- activity Increased amount of substrate in serum Prenatal

diagnosis in amniotic fluid Enzyme therapy for EDD like Galactosemia Glu.6.phosphate dehydrogenase Chole esterases
Phenylketonuria Albinism,alkaptonuria etc.

- ENZYME DEFICIENCY DISEASES Diseases Enzyme Gout (X linked recessive) PRPP Synthase Lesch Nyhan Syndrom
hypoxanthine-guanine- Phosphoribosyl transferase Cystic fibrosis DNase Alcaptonuria Homogentisate oxidase Maple syrup
urine disease (various forms Branched-chain ketoacid dehydrogenase Immunoinsufficiency( autosomal Recessive)
Adenosinedeaminase Disease Enzyme Tay-Sachs disease hexosaminidase A Krabbe's disease b-galactosidase Niemann-Pick
disease sphingomyelinase Farber's disease ceramidase Fabry's disease a-galactosidase Alcaptonuria homogentisate oxidase
Gauchers desease b-glucosidase Lactose intolerance Lactase

LDH,etc.

- Enzyme inhibitors & Drug Design Drug/Inhibitor Enzyme Disease Mevinolin, Copactin, Monacolk HMG CoA Reductase
Hypercholesteremia Penicillins & antibiotics Peptidyl transferase, RNA polumerases,DNA Polymerases etc. Infections after
Surgery,Other infectious diseases Allopurine Xanthine Oxidases Gout, Hyperureamia HIV Protease Inhibitors HIV Proteases
AIDS Methotrexate Folate reductase Cancer,infections Ethanol Alcohol Dehydrogenase Methanol poisoning,

-
-chloroehyl aminobezoyl glu. Benzoic acid mustard Carboxypeptidase-G2 Mtomycin
phosphate mitomycin ALP Aniline mustard glucuronide Aniline mustar Glucuronidase 5-flurrocytosine 5-flurouracinl Cytosine

- Assay of Plasma Enzymes Should have a normal range in the plasma Elevated levels are seen in diseases Increased levels due to

damaged tissue used in forensic science.

- ENZYME IMMUNO ASSAY Indirect method for measuring the concentration of substrate Enzymes are used as a type of
amplification system Can measure conc. Of hormones, drugs, antigenic determinants of pathogens etc. Based on the specificity of
ag-ab reaction Eg:ELISA, Greater specificity, stability, sensitivity, avoiding radioactive subtances than RIA
The Use of Enzymes in Medicine

Enzymes are produced by living cells they are substances that act as a catalyst in living organisms, increasing the rate at which
reactions take place without itself being effected in the process. Without them, reactions in cells would proceed at a too slower
rate to sustain life. They are able to speed up the rate of chemical reactions. All enzymes are proteins and therefore have a tertiary
structure. Each enzyme is a specific shape with an active site which is specific to one substrate molecule. When the substrate
combines with the active site enzyme substrate complexes are formed.

Enzymes have several valuable industrial and medical applications. Due to the catalytic activity of enzymes they are able to be
used in a variety of ways; Examples are in the fermenting of wine, the paper industry, starch industry, leather industry, baking
industry, beer brewing industry, washing detergent industry and in the pharmaceutical and diagnostic industry. The uses of
important enzymes in medicine include killing disease-causing micro organisms, prompting wound healing, and diagnosing
certain diseases.

Enzymes are used heavily in medicine. These applications include using enzymes as direct pharmaceutical products. In this essay
I am going to look at the importance of enzymes in medicine and a few of the many different applications they undertake.

For many years we have used enzymes to produce the things we rely on for example in cheese, bread, wine, beer and yogurts.
Now due to our much more diverse commercial applications for example using enzymes in medicine the sale of enzymes is a
multi billion pound industry.

The medical and pharmaceutical application of enzymes covers such a wide range of ideas. In contrast to industrial uses where
production is on a much larger scale; uses of medical and pharmaceutical enzyme applications generally require small quantities
of highly purified enzymes. Enzymes and enzyme-generated products are administered to patients in very small doses; this is in
order to avoid possible side effects.

The first example I will look at is the use of enzymes in medicine is analytical tests. Enzymes can be used to detect and measure
amounts of glucose in blood. The amount of glucose in the blood and urine is a crucial indicator in the diagnosis of diabetes; this
is when there is a deficiency of insulin resulting in high glucose levels in the blood. It is detected using the enzyme glucose
oxidase which is impregnated onto a strip of paper, and a biosensor. This instrument uses glucose oxidase as its biological
system. The enzyme catalyses the reaction between glucose and oxygen to form gluconic acid. The biosensor then uses the
amount of gluconic acid produced to indicate the quantity of glucose and oxygen there was in the blood this is indicated by an
color change.

Enzymes are very important when coming to diagnose disease; this is because if enzymes are present where they should not be
then something may be wrong. An example of this is in the case of a damaged liver. Enzymes that would be normally found in
the liver, leak into the blood stream. By testing the blood for alternate enzyme activity liver damage can be confirmed.

Enzymes are vitally important in preventing excessive blood clotting and reducing the tendency for platelets and red blood cells
to ‗clog‘. Because of enzymes part in removing metabolic waste and improving circulation proteases for example; Trypsin and
chymotrypsin can be used in fibrinolysis, this a process that dissolves blood clots. One use is in the case of thrombosis, this is
when blot clots form in damaged blood vessels, if these clots are carried to an small artery and may become blocked a heart
attack or stroke can be caused. This can be treated by enzymes such as trypsin and protease. Digestion of the insoluble fibrin clot
takes place and because the enzymes are proteins this results in a conversion to amino acids, consequently freeing the trapped
blood cells and eliminating the clot. This process is called fibrinolysis. Opposite to the prevention of clotting; the enzyme
protease can be used as a debriding agent they are used to clean the wound and accelerate the healing process.

Enzymes can also be used in drug manufacture where the synthesis of drugs is difficult therefore enzymes are used to perform the
chemical procedure. Enzymes can also be used to aid digestion where they are used to supplement amylase, lipase and protease
produced mainly by the pancreas. An example is lactose intolerant people where they require lactose as their bodies are not
producing it.

The last point in enzyme application in medicine I will talk about is the production of antibiotics in particular penicillin. The
major pharmaceutical; products produced using enzyme technology are the antibiotic, semi-synthetic penicillins.

Antibiotics are chemical substances produced by micro organisms which are effective in dilute solution in preventing the spread
of other micro organisms. Most inhibit growth rather than kill the micro organism on which they act. One of the best known
antibiotics is penicillin – discovered by Alexander Fleming in 1928. It was found that it acts on growing bacteria, killing them
and preventing their growth. It is believed to compete with paraaminobenzoic acid for the active site of an enzyme. In this way
they do not kill the bacteria but simply stop them from reproducing.
Although it has been very successful since its discovery in 1928 and has had an enormous influence on the control of disease,
antibiotics have one serious drawback this is that due to the development of resistance towards antibiotics by pathogens there is a
continuing need to find new types. Each time a new one is used resistant strains of micro organisms arise which further drugs
have to be developed. In my opinion new developed drugs should therefore be used with much more restraint and discrimination
and more time should be used searching for natural antibiotics to the development of new strains using genetic engineering.

In this essay I have outlined and explained only a small number of the uses of enzymes in medicine however there are many more
successfully developed uses. Examples include, in the treatment of genetic defects, the development of artificial organ function,
neoplasm, anti–inflammatory reagents, drug manufacture, the removal of chiral components and to aid digestion.

In the 20th century the use of enzymes in pharmaceutical and industry is limited to a low number of very successful applications.
However it is the very success of such applications that continues to help pave the way for new developments and it is clear that
there is no shortage of ideas. After having an insight to the application of enzymes in the medical and pharmaceutical problems I
have realized that it is an exciting and promising field that is ripe for development in the near future.

Enzyme Therapy
Other common name(s): digestive enzyme therapy, pancreatic enzyme therapy, systemic enzyme therapy, proteolytic enzyme
therapy

Description
Enzyme therapy involves taking enzyme supplements as an alternative form of cancer treatment. Enzymes are natural proteins
that stimulate and accelerate many biological reactions in the body. Digestive enzymes, many of which are made in the pancreas,
break down food and help with the absorption of nutrients into the blood. Metabolic enzymes build new cells and repair damaged
ones in the blood, tissues, and organs.

Overview
Available scientific evidence does not support claims that enzyme supplements are effective in treating cancer.

How is it promoted for use?

Enzymes are sometimes used in mainstream medicine. For example, the approved chemotherapy drug asparaginase is an enzyme.
Some enzymes are also used for other serious illnesses. Pancreatic enzymes may be given to treat digestive problems resulting
from removal of the pancreas or certain diseases of the pancreas.

However, some alternative medicine practitioners claim that digestive enzyme supplements not only relieve digestive problems,
such as ulcers and food allergies, but also strengthen the immune system, improve circulation, ease sore throat pain, aid weight
loss, and relieve hay fever, ulcers, and rheumatoid arthritis. Proponents also claim that certain enzymes remove a protective
coating from cancer cells, allowing white blood cells to identify and attack them.

What does it involve?

Human cells naturally produce about 10,000 different enzymes which are essential in normal metabolism. Enzyme supplements
are extracted from animal organs and some plants such as pineapple and papaya (see Bromelain). Among the most popular
enzyme supplements are pancreatic enzymes, which come from an animal pancreas.

Enzyme supplements are available in pills, capsules, and powders. Supplements often consist of combinations of several
enzymes. Large amounts of the supplements are often taken each day. There is currently no established safe or effective dosage.

Enzyme therapy is a part of some forms of metabolic therapy, including Gerson therapy and the Kelley and Gonzalez programs.
(For more detailed information on these regimens, see our documents on Gerson Therapy and Metabolic Therapy.)

What is the history behind it?

Pancreatic enzymes were reportedly first used to treat cancer in 1902 by John Beard, a Scottish scientist. German researchers
later used enzyme therapy to treat patients with multiple sclerosis, cancer, and viral infections. Some enzyme mixtures are still
commonly used in several European countries.

Dr. Edward Howell introduced enzyme therapy to the United States in the 1920s. He believed that by eating raw meat, people
created an enzyme surplus in the body, which resulted in better health and increased resistance to disease. Other practitioners
have advocated the use of enzyme therapy since then, often as part of a larger metabolic therapy regimen. At least one enzyme
preparation is currently being studied in the United States for use along with chemotherapy in cancer patients.

What is the evidence?

There have been no well-designed studies showing that enzyme supplements are effective in treating cancer. Experts question
whether enzymes taken by mouth can reach tumors through the bloodstream, as the enzymes are broken down into amino acids
before being absorbed in the intestine.

Studies of enzyme supplements to ease the side effects of cancer treatment have had mixed results. Two studies done in India
reported that side effects of radiation therapy in cancer patients taking pancreatic enzyme supplements were less severe than in
those taking a placebo. However, these studies were not blinded, meaning patients and their doctors knew whether they were
taking the actual enzymes. This means that the results might have been affected by the expectation of improvement, or placebo
effect. A blinded German study in which patients did not know whether they were taking the enzymes or placebo pills did not
find any benefit.

Several studies done mainly in Eastern Europe have looked at the possible effects of adding enzyme supplements to mainstream
cancer treatment. They have generally found that supplements may improve quality of life and could possibly have other benefits.
However, these studies are not considered scientifically strong. They looked back in time at patients who were already treated
and were not randomized or blinded. A randomized study of the addition of enzyme therapy to standard chemotherapy for
multiple myeloma patients is under way in the United States.

A small study of patients with pancreatic cancer—conducted by Dr. Nicholas Gonzalez and published in Nutrition and Cancer in
1999—found that patients treated with pancreatic enzymes survived longer than typical patients with pancreatic cancer.
However, in a recent review of alternative cancer therapies, an expert in integrative oncology research methods noted that, "The
study was small and obviously prone to several biases. Not only is the comparison with national averages unadjusted for
confounders, but the principal results are based on patient selection; twelve patients who did not comply with treatment were
excluded from analysis." Well-designed scientific studies control or adjust for confounders, factors besides the method being
studied—such as age or cancer stage—that can affect outcome. They have a control group that receives the standard treatment
alone, and they generally also include patients who did not complete treatment in the final analysis.

A randomized clinical trial has been sponsored by the National Cancer Institute to evaluate the Gonzalez regimen for treating
pancreatic cancer, but no results of this trial have yet been published in a peer-reviewed medical journal.

Are there any possible problems or complications?

This product is sold as a dietary supplement in the United States. Unlike drugs (which must be tested before being allowed to be
sold), the companies that make supplements are not required to prove to the Food and Drug Administration that their supplements
are safe or effective, as long as they don't claim the supplements can prevent, treat, or cure any specific disease.
Some such products may not contain the amount of the herb or substance that is written on the label, and some may include other
substances (contaminants). Actual amounts per dose may vary between brands or even between different batches of the same
brand. Most such supplements have not been tested to find out if they interact with medicines, foods, or other herbs and
supplements. Even though some reports of interactions and harmful effects may be published, full studies of interactions and
effects are not often available. Because of these limitations, any information on ill effects and interactions below should be
considered incomplete.There is very little information available on the safety of enzyme supplements. Some manufacturers
recommend that people taking blood-thinning medications speak with their doctors before taking enzyme supplements.

Care should be taken to make sure that any diet containing raw meat or juices from raw meat is free from bacterial
contamination, especially for people with weak immune systems.

Some people are allergic to the materials from which the enzymes are made. Be sure to know the source of any enzymes you are
considering.

Women who are pregnant or breast-feeding should speak with their doctor before using this method. Relying on this type of
treatment alone and avoiding or delaying conventional medical care for cancer, may have serious health consequences.
Enzymes for Cancer: Low Enzymes Are Always Found In Cancer

Use The Right Enzymes To Kill Cancer Cells

Enzymes for Cancer - Lipase

Enzymes for Cancer - The Lipase Enzyme.

Researchers have noted for years a correspondence between low levels of enzymes and cancer. In fact enzyme therapy has been
used with good results against cancers in Europe, and by some doctors in the United States. To literally digest cancerous cells.

In the early 1900's a doctor in Wales, John Beard discovered that pancreatic enzymes destroyed cancer cells. Making some
brilliant observations, he deduced that cancer cells come from stem cells that become uncontrolled stem cells. He noticed that the
fetal pancreas starts working and secreting enzymes at the 56th day of gestation. Fetuses don't digest anything till they are born.
Beard wondered why did the pancreas in the fetus start working so early? He noticed that the day the pancreas started producing
enzymes was the day the placenta stopped growing. The enzymes stopped this rapid growth.

His theory about enzymes and cancer was that many placental cells remain in our body. When these misplaced placental cells get
lost and can start growing, turning cancerous if you don't have enough pancreatic enzymes. (By the way the medical community
thought Dr. Beard was crazy. Now a hundred years later, technology has confirmed there are these cells.)

In 1911 he tested pancreatic enzymes for stopping cancer in mice and it worked. Naturally and unfortunately, he was blackballed
and died in obscurity. Decades later Dr. Kelly read about his work, and cured himself of cancer using pancreatic enzymes and
started treating and curing many cancer patients using pancreatic enzymes. Dr. Gonzales, sent to investigate Dr. Kelly, liked what
he saw so much that he also treats cancer using pancreatic enzymes.

The major reason enzymes levels become depleted is that we eat mostly processed, irradiated and cooked food.

The digestive system was designed to process raw food. Raw food, when it is picked ripe, has enzymes in it that help break down
that food in the upper stomach where it sits for 30 to 45 minutes. The enzymes in the food predigest that food. Then in the lower
stomach the pancreas excretes more enzymes.

When you eat cooked, irradiated and processed foods, the enzymes have been killed; the food does not predigest in the upper
stomach. So when it reaches the lower stomach two things happen. The pancreas must make extra enzymes to try and break down
the food.

And often the food is only partially digested.

The pancreas, after decades of overworking, eventually is no longer able to produce an adequate supply of enzymes. So you
develop low enzyme levels of all types of enzymes, and your body cannot naturally kill cancerous cells using enzymes.

In addition, food that is not completely digested all too often makes its way into the bloodstream. Especially if you have leaky gut
syndrome from candida overgrowth. This partially digest food is treated as a toxin, and the immune system has to get rid of it.
This puts an additional strain on the already overworked immune system.

Studies have found that the immune system treats the ingestion of cooked food as a toxic poison, causing a jump in white blood
cells in an attempt to get rid of it as fast as possible.

Taking a good quality enzyme supplement with meals, one that has high levels of protease to digest protein, lipase to digest fat,
and amylase to digest carbohydrates helps break down food in the upper stomach. So that the pancreas doesn't have to produce
extra enzymes. Food is better digested. Regarding enzymes and cancer, the one we suggest as having the most enzymes for the
value is
P-A-L Plus Digestive Enzymes

A bottle will last 2 months. Also, it is important to take enzymes on an empty stomach. A stack of research shows that enzymes,
when taken in this manner, will go into the bloodstream and clean it up. And in the process digest and kill cancer cells. Take both
a plant based digestive enzyme along with pancreatic enzymes high in Trypsin and Chymotrypsin for the best results. Take both
with meals for improved digestion, and on an empty stomach to get into the body.

This will also unstick clumpy red blood cells. Sticky, clumped up red blood cell clusters clog up capillaries and reduce
circulation. So that cells cannot oxygenate properly. Which as you have gathered by now, contributes to cancer.

Cancer tumors produce a thick fibrin protein to help protect them from the immune system. This also helps to stick the cancer
tumor to wherever it is.

Enzymes in the bloodstream can digest and dissolve the fibrin coating. Large amounts of enzymes would need to be taken, and
they would need to be enzymes high in protease or nattokinase to break down the fibrin.

The pancreatic enzyme protocols for treating cancer make use of large amounts of pancreatic enzymes. They are taken on an
empty stomach so they can go into the body to digest cancerous cells. And are taken with meals so that your pancreas doesn't
have to produce as many enzymes to digest your food. This allows the pancreas to produce more enzymes to send into the body
to fight cancer. The enzymes naturally produced by the body will be more effective than any enzyme supplement. Thus the
protocols tend to use more enzymes with meals than taken on on empty stomach.

A bit more potent than the pancreatic enzyme formulations though, with the best one we have found coming in at 298, is a
formulation of mature green papaya powder with additional support nutrients. The product is:

The main ingredient in this formula is mature green papaya powder. Papain is the principal and most active enzyme in this
powder. Papain possesses a very powerful digestive action superior to pancreatin, or pancreatic enzymes. Changes in intestinal
alkalinity or acidity do not interfere with the unique digestive activity of papain. Taken on an empty stomach, it will work more
aggressively than even the pancreatic enzymes in attacking and destroying cancer cells.

Taken with a meal, it will also help digestion. Papain, one of the most powerful plant proteolytic enzymes, will aid in protein
digestion in an acid, alkaline or neutral medium. This is of vital importance if you are enzyme deficient or have low hydrochloric
acid output in the stomach. The pepsin produced in the stomach for protein digestion is activated only in an acid medium. This
requires a healthy output of hydrochloric acid which is insufficient in most people. Due to the powerful proteolytic action of
papain, a more active digestant than pepsin, a major digestive problem for most people will be helped by the daily ingestion of
mature green papaya powder.

The second major cancer fighting ingredient in PapayaPro is Citrus Pectin. It has the potential to prevent metastasis, or the spread
of cancer. Modified citrus pectin‘s small molecules enter the bloodstream and act as decoys for lectins (cancer cell surface
proteins), which are seeking the sugar galactose in cells. When lectins encounter the pectin, which also contains galactose, they
attach to it as they would to a cell. Once bound to the pectin, lectins are unable to attach to other sites in the body and start new
cancer colonies. Thousands of research studies have demonstrated citrus pectin's cancer fighting abilities.

PapayaPro also contains other immune boosting and cancer fighting ingredients such as mangosteen powder that act
synergistically with the papaya powder. Use one to two of the 300 gram containers monthly on an empty stomach to fight cancer.
Get an extra container if your digestion is poor and you want help breaking down protein. Energetic testing puts PapayaPro at
830 for its healing power for cancer. Its papaya enzymes will, on an empty stomach, get into the bloodstream and work to clean it
up. Most importantly, it will digest dead cancer cells that the other cancer supplements are killing. This will take a big load off
the detoxification system and help to reduce detox symptoms and inflammation of the tumors. This will also help to reduce tumor
size faster, another benefit from using enzymes for cancer.

Their extremely high levels of protease will also help to break down the fibrin coating all cancerous tumors so that the immune
system can better attack those tumors. In addition it will digest the live and dead cancer cells inside the tumors, helping to bring
down tumor size faster. Use 1 to 3 containers a month for helping to support the detoxification process by digesting dead cancer
cells. Use 4 to 6 bottles a month if you have tumors or bone cancer that are causing a great deal of pain or dysfunction. This
quantity will work faster to reduce tumor size, and does a better job of helping to bring down tumor size than just about anything.
It still won't be fast, but it will be faster than it would have been.

Here is what you need to use if you are suffering from muscle mass loss caused by catabolic wasting.
Catabolic Wasting Protocol

Catabolic wasting can occur in the end stages of cancer, aids and other serious illnesses. It is a major cause of death in cancer. No
matter how much someone eats, how much nutrition they get, they lose weight and muscle mass. They are not able to metabolize
or make protein. Recently scientists have figured out why this happens.

Dr. Chojkier and Martina Buck, Ph.D., of VA, UCSD and the Salk Institute for Biological Studies, described the steps by which
tumor necrosis factor (TNF) alpha, an immune-system protein, prevents the production of albumin. Low levels of albumin, a
critical protein made in the liver, is a keynote of wasting.

Drs. Buck and Chojkier showed that TNF alpha causes oxidative stress in the liver cell and also causes the addition of a
phosphorous molecule to a protein called C/EBP beta, which normally joins together DNA in the nucleus of the cell to make
other proteins, such as albumin.

This extra phosphorous causes the C/EBP beta protein to leave the nucleus and go into the cytoplasm, where it can no longer
make the albumin."We found that this phosphorylation makes the C/EBP beta exit the nuclear area and go into the cytosol, where
there is no DNA for it to bind with. This means it can no longer produce the protein," said Dr. Chojkier. And this inability to
produce albumin leads to the muscle wasting and weight loss.

The researchers found several ways of stopping the downward spiral caused by TNF- alpha. One way was to use antioxidants,
especially ones that focus on the liver. This blocked the chain of events leading to the export of C/EBP beta from the nucleus of
the liver cells. "If we block oxidative stress, we normalize everything," explained Dr. Chojkier. "C/EBP beta remains in the
nucleus, it contacts the DNA, and proteins are produced.

As you can see, protecting the liver and normalizing liver function is vital to reversing or stopping wasting. If you don't stop
wasting, you won't make it. You'll basically end up being killed by the wasting before the cancer kills you.

Fortunately, there is a protocol to stop catabolic wasting. You can notice improvement in a couple of weeks. Follow this protocol
for at least two months to completely stop the wasting. Continue to take other anti-cancer supplements in advanced stage dosages
while using this protocol. There are two products in this protocol.

Regeneration Elixir

Three bottles of this frequency enhanced water elixir is a month's supply. It stimulates cells to repair themselves, and does a
stronger and better job of this than our previously recommended Rejuvin. With catabolic wasting the liver needs repair so that it
can start processing proteins again. What happens with Regeneration Elixir is that the water in it carries specific energetic
vibrational frequencies that signal or turn on the regeneration and repair process in your body. Take 3 squeezes of the dropper
twice a day. You will read more about energetic elixirs in the Energy section following this section.

Fulvitea

This is the second and most important supplement you need to use to reverse catabolic wasting and to start gaining some weight.
In fact, in is one of the most important products to use whenever to liver is poorly functioning. And whenever the cancer is so bad
that you are essentially starving to death. The predigested protein it supplies is usable by the body without the liver having to
convert amino acids to protein. And the regenerative factors in it help to stimulate repair. As the liver is so vital to health, if the
liver is poorly functioning, the body uses the nutrients in Fulvitea to repair the liver. It does an excellent job. We have heard
consistently successful reports of it stopping catabolic wasting and improving liver function - even with cirrhosis. In a life and
death situation, be sure and use Regenerative Elixir to more rapidly improve liver function.

Fulvitea has two basic functions. First it is a source of pre-digested protein that your body doesn't have to process to use. So you
can actually start making muscle again. In addition it contains RNA and DNA repair factors to stimulate repair of the liver and
also of cancer cells. It helps to normalize cancer cell function so the cancer cells die a normal death, apoptosis.

This 1 pound container of powder contains Hydrolyzed Marine Collagen from wild fish which is 95% pure protein in a
hydrolyzed (broken down) amino-acid form. In addition it has Fulvic Acid powder which intensifies the metabolism of proteins,
increases DNA content in cells and increases the rate of RNA synthesis. The Green Tea Extract in it helps to drive the nutrients
into the body. And does have anti-cancer benefit.

It also supplies freshwater Diatomaceous Earth which will aid the detoxification process and fight cancer. Whole Colostrum
powder (Grade A Bovine) supports the regeneration process and boosts immune system response against cancer. Small amounts
of Vitamin C, Zinc, ProCoQ10, Manganese, Vitamin B6, Niacinamide, Selenium, Molybdenum, Chromium, and Vitamin E a
blend of herbs that also support the regeneration process.
Fulvitea also contains NutraFlora - a short-chain Fructooligosaccharide assisting in the absorption and utilization of minerals and
amino acids. It passes, intact, through the stomach and small intestine to the colon, where it is fermented by beneficial bacteria
into short-chain fatty acids. These lower intestinal pH to an optimal level for keeping calcium, minerals and amino acids in
solution for a longer period of time, making them much more absorbable. Absorption is further enhanced by Aulterra magnetic
powder from an ancient seabed mineral deposit. Aulterra supports the utilization and effectiveness of nutraceuticals and herbs in
the diet. And Pascalite - a rare, calcium bentonite/montomorillonite, non-swelling clay, which has a long history of health uses.
Pascalite provides trace minerals in oxide form, so they are easily assimilated.

Use 2 containers a month if you are not in too bad a shape, and 3 to 6 containers a month for more serious nutrient support and
liver repair., its energetic testing for helping stop catabolic wasting is 1030. This is clearly one of the most important cancer
fighting supplements to take for end stage cancers and all cases of catabolic wasting.

We find it works best to shake or blend the powder into a smoothie or some sort of drink but not a protein drink as it is best
absorbed on an empty stomach without other proteins.

There is a well known product that has been fighting cancer and used for wasting for years. It is a fermented soybean protein
drink. For wasting and advanced cancers you need to drink a bottle a day of this bad tasting drink. Quite expensive too at $50 a
bottle. For fighting cancer, energetic testing puts it at 321. Respectable, but not near as powerful as Fulvitea which comes in at
460 for its ability to fight cancer. For catabolic wasting it comes in at 353, again much less than Fulvitea's 1030.

Use Regeneration Elixir and Fulvitea for catabolic wasting. You should see results quickly, and be able to successfully stop
catabolic wasting in its tracks. 3260

How systemic enzymes work to cure diseases?

Aging appears to begin between the ages of 27 and 35 when the production of enzymes that dissolve protein begins to diminish.
Enzymes are widely recognized for their importance in digesting food. They also break up circulating immune complexes in the
blood. Enzymes can act to prevent too much fibrin from being deposited in wounds, fractures and joints. These enzymes also
remove necrotic debris and excess fibrin from the blood stream. Immune system regulation can also be accomplished with
enzymes. Most of the development of systemic enzyme therapy was carried out in the Far East and Europe. Enzyme therapy is a
prime example of a situation in which US medicine is missing the boat due to a lack o of awareness of what the rest of the world
is doing and our unwillingness to use therapies not made by ―big pharma.‖ Enzymes can not be patented so they are of little
interest to drug companies.

The proteolytic enzymes used in enzyme therapy dissolve fibrin. When strong proteolytic enzymes are in an enzyme preparation,
they can be powerful enough in their action to actually gradually digest scar tissue away. This takes time to occur, of course, but
eventually all the scar tissue may disappear.

Sometimes when the body deposits excess fibrin in a tissue the tendon sheaths become thickened and the free movement of a
tendon back and forth fails to occur with the tendon getting caught in the fibrous tissue (e.g. trigger finger, Dupytron‘s
contracture of the palm, etc.) and failure of normal function occurs. Tissues containing excess fibrin are weak because they do
not provide adequate space for the epithelial tissue that normally grows through the whole fibrin matrix, producing strength.

These tissues with excess fibrin have restricted motion if joints are involved and will have diminished size and function if the
scarring involves an internal organ(e.g. heart after infarction, kidney after a clot to a kidney artery, pancreas after episode of
pancreatitis, etc.)

Systemic enzymes have a unique feature. Side effects do not occur with systemic enzymes. This means that raising the dosage to
massive levels does not cause any problems unlike pharmaceutical drugs. The initial dosage, which is often one potent enzyme
pill three daily taken 45 minutes before or 45 minutes after a meal, can be raised by three tablets daily every few days until the
desired therapeutic response develops.. A person given more than 3700 enzyme tablets in one day experienced only diarrhea from
this massive capsule intake.

A second interesting facet of systemic enzymes is that their effects on coagulation intensify the actions of blood thinning drugs
like coumadin. Fibrin digests with enzymes which dissolves blood clots.Persons on anti-coagulant drugs and individuals with
hemophilia may have more intense bleeding with enzyme therapy, and should avoid using enzymes.

Use of Vitalzym in Disease Conditions

Vitalzyme + is an enzyme formulation that contains protease, serrapeptase, papain, bromelain, amylase, lipase, rutin and amia,
which is a rich source of vitamin C. Serrapeptase is a unique proteolytic enzyme isolated from non-pathogenic enterobacteria
Serratia E 15 that has superior anti-inflammatory action[1] when compared to other proteolytic enzymes. Serrapeptase is the
enzyme found in the intestine of the silkworm that permits the silkworm to break out of the cocoon.

In addition to breaking down fibrin deposits, Vitalzyme+ reduces inflammation, removes and filters viruses from the blood,
balances the immune system, and removes toxins from the blood. The systemic effects of enzymes can be used to prevent and
resolve many diseases. The rutin contained in Vitalzym has valuable properties. Rutin is a bioflavinoid which composes 4-6% of
buckwheat. Rutin strengthens and controls the permeability of blood vessels and capillary walls. This turns weak blood vessels
into strong ones that are less likely to bleed. Rutin lowers the blood pressure and slows aging.
Bioflavinoids, such as rutin, quercitin, and hesperidin, are powerful antioxidants that effectively combat free radicals believed to
cause 90% of diseases(cancer, arteriosclerosus, arthritis, aging etc.) Other enzyme formulations such as Nattokinase,
Lumbrokinase, and Wobenzym contain potent enzymes such as chymotrypsin which make them very effective.

Many articles have been written recently extolling the virtues of serrapeptase. Serrapeptase has anti-inflammatory, anti-edema,
and fibrinolytic properties. A study in otolaryngological patients from many centers in Italy disclosed that serrapeptase was very
effective in alleviating thick infected secretions.[2] Ninety one percent of those taking serrapeptase reported good to excellent
results compared to 22% in the control subjects. Knee cartilage operations were followed by 50% less swelling[2] in the group of
patients taking serrapeptase. Patients with fibrocystic breast pain[3] reported 85% marked to moderate improvement compared to
65% not receiving serrapeptase. Twenty patients (average age 39) with carpal tunnel syndrome[4] were given 10 mg of
serrapeptase twice daily. Thirteen of these were better with electrophysiologic proof of recovery.

Enzyme Therapy In Malignancies

In Europe, therapy of malignancies usually includes enzymes in large dosage which has lengthened survival. Enzyme
preparations are carefully formulated so they are able to avoid dissolving in stomach acid and thus are available to get into the
blood without being destroyed.

In cancer cases, the cancer cells are surrounded by a layer of fibrin which may be up to 15 times thicker than the layer of fibrin
that surrounds normal cells. This fibrin layer permits these malignant cells to escape destruction by killer immune cells, which
are unable to detect the cancer cell antigens. The systemic enzymes are able to remove this fibrin coating, permitting the immune
cells to again kill the tumor cells. Additionally, immune cells become stimulated by enzymes to increase the production of tumor
necrosis factor which can attack tumor cells, as well as cells infected by viruses. This is vital to cancer defense. Systemic immune
therapy has prolonged life for many patients, and in the case of cancer of the pancreas, Dr. Wyba states that about one-third of
cases have been cured using Wobenzyme. The enzymes must not be stopped or the cancer recurs. The dose may need to be as
much as 30 pills three times daily. We think it may be wise to include enzymes along with other therapies in treating cancer.

Enzyme Therapy in Infections

The human body reacts to infections by increasing the viscosity of the blood. This slows the flow of blood and increases the
clotting tendency of the blood. At times, the clotting tendency is so exaggerated in infections, malignancies and other disease
states that there is widespread occurrence of fibrin clots all over the body (disseminated intravascular coagulation). In this state,
all of the blood‘s substances that are needed to cause the blood to clot become consumed, resulting in no ability to clot. This
leads to widespread hemorrhagic are at the same time there is a multitude of clots. Systemic enzyme therapy stops the clotting
tendency of blood that occurs in infections by its action to dissolve fibrin. There is an increased risk of heart attacks and strokes
immediately after acute infections (Chlamydia, Cocksackie viruses, etc.) and in persons suffering from gingivitis.

Viral and Bacterial Infections

Many infectious problems that trouble humans come to light when a dormant virus becomes activated after residing harmlessly
for many years. A good example of this is herpes zoster skin infection developing in patients who had recovered from an old
chicken pox viral infection (varicella zoster) many years previously. Herpes viruses may lie dormant for many years, only to
produce very painful neuritis at a later date.. This may follow an acute illness or any event that injures the immune
system(chemotherapy).

When a virus contacts a human cell, the external coating connects to the cell, and the virus becomes able to contact DNA. This
connection to DNA permits the virus to reproduce in a rapid manner. Proteolytic enzymes consume the exterior coating of a virus
rendering the virus permanently inert. To recover from a viral infection requires that enough enzymes be taken to get ahead of the
rapid viral replication within cells, This may require 5-10 capsules of Vitalzyme + three times daily or more.
Biofilm Protection for Bacterial Infection Involving Prosthetic Substances

One of the problems plaguing medicine currently is infection of prosthetic substances placed in the body(prosthetic hips, knees,
heart valves. etc.) These infected prosthetic parts often need to be replaced, as their infection can not be eliminated. Bacteria are
able to create a biofilm that prevents antibiotic drugs from reaching and killing them. A similar problem exists in heart valve
infections, where frequently an emergency replacement of an infected valve leaflet becomes the only way to save the patient‘s
life. The proteolytic enzyme serrapeptase was shown to enhance the killing activity of the antibiotic Ofloxin in cultures and to
prevent the formation of biofilms.[5] This prevention of biofilms could become very valuable in treating these problem
infections.

Enzyme Therapy in Allergic Diseases

There is an inflammatory component to the asthmatic attack. Use of enzymes during an acute episode should be effective therapy
in many persons. Decreasing the volume of secretions and causing the secretions to become less viscous so they could be easier
to cough up is also beneficial. Maintaining a low dosage of enzymes, 2-3 capsules daily, should also create an environment in
which it would be more difficult for a new attack of asthma to get started.

The allergenic pollens irritating the nose in allergic rhinitis(hay fever) cause the production of considerable mucous secretions.
Taking enzymes should decrease the volume of these secretions and thus alleviate the symptoms. As in asthma, taking 2-3
enzyme capsules daily could prove valuable by making it more difficult for hay fever symptoms to be initiated.

Use of Enzymes in Painful Conditions

Proteolytic enzymes are able to block the release of pain producing amines from tissues that have inflammation. This elimination
of pain benefits many conditions. The disability of migraine headaches can usually be helped by enzyme therapy. Sinus
headaches can be alleviated by enzymes, which decrease and liquefy secretions that contribute to the pain. A group of 59 patients
with acute and chronic sinusitis were assigned to receive either the enzyme bromelain or placebo along with conventional therapy
(antibiotics, decongestants, etc.) The group getting bromelain seemed to improve because it dissolved fibrin leading to improved
absorption of edema fluid, thus enabling greater penetration of immune system components. Obviously, one of the more valuable
uses for enzymes is to relieve the pain in arthritic conditions, bursitis, and synovitis.

Lung Disease and Enzyme Therapy

Pulmonary Fibrosis: In pulmonary fibrosis the thin, filmy, alveolar membrane, which permits oxygen to enter the bloodstream
and enables carbon dioxide to pass from the blood into the lung air spaces , becomes progressively thickened by the laying down
of fibrin deposits on the alveolar membrane. These thickened alveoli do not permit normal oxygen for carbon dioxide exchange
in the lung. Shortness of breath then appears with exertion.

Many disease states can cause a chest x-ray appearance identical with that of pulmonary fibrosis. These conditions include
cancer, infections, inhaled irritants(asbestosis, silicosis, beryllium, etc.), sarcoidosis, diseases of connective tissue (lupus,
rheumatoid arthritis, scleroderma), and adverse drug reactions (more than 50 can cause fibrosis including 14 chemotherapy drugs,
sulfa, penicillin, furadantin, hydralazine, aprèsaline, gold, chlorpropamide, allopurinol, hydrochlorthiazide, and dilantin).
Standard therapy for pulmonary fibrosis includes courses of cortisone and immunosuppressive drugs (Imuran etc.) if cortisone
fails to benefit.

Since pulmonary fibrosis has progressive scarring and an inflammatory reaction in the alveoli, therapy with systemic enzymes
that digest fibrotic tissue and block the inflammatory reaction should be a safe rational approach. Vitalzym + is helping patients
with pulmonary fibrosis. Start with 3 capsules three times daily on an empty stomach and raise the dosage at regular intervals
until improvement is noted.

Sarcoidosis A disease of unknown cause, sarcoidosis is more common in Afro-American than Caucasians. The disease causes
nodules and scarring in the involved organs, Sarcoidosis is often discovered by a routine chest xray revealing shadows in an adult
with no symptoms. The lung is the most common organ involved with the disease but the eyes, skin, nervous system, bones, and
joints may also be involved.

Lung symptoms may include cough, shortness of breath and wheezing. When the lung symptoms are advanced or the disease
involves critical structures(eyes, nervous system) cortisone therapy is usually effective. Often it is impossible to discontinue
cortisone, which may need to be maintained in low dosage.
A promising therapy for sarcoidosis is systemic enzymes for a trial period of 2-3 months. The inflammatory granulomas and scar
tissue(fibrosis) in the lung, eyes, bones, joints and skin might very well be terminated by this therapy which is much safer than
cortisone. Regular increase in enzyme dosage will reach levels where resolution of fibrosis can occur.

Use of Enzymes in Arthritic Diseases

Enzymatic therapy can benefit all forms of arthritis by reducing inflammation, alleviating pain, and stopping the circulation of
inflammation causing immune complexes. For these reasons many arthritis products contain enzymes(bromelain,papain, etc.)
Wherever there is pain there is inflammation which can be blocked by enzymes.

Systemic Lupus Erythematosus

A key feature of SLE is allergic reactions in body tissues (auto-immunity). Circulating immune complexes are routine, and the
sites where they deposit determine the symptoms of this disease, (lining membranes overlying lung, heart, abdomen, joints, brain,
skin, etc,) A trial of systemic enzymes could remove these circulating immune complexes from the blood of the SLE patient.
Several months of enzyme therapy might have a dramatically beneficial effect on the disease. High dosage initially is a good
idea.

Fibromyalgia

Fibromyalgia (FM) afflicts approximately 6 million persons in the USA, predominately women in the 20-40 age bracket. FM is
characterized by severe muscle pain, tenderness in 18 points where muscle and tendons merge, fatigue, headaches(50%), and
severely impaired sleep.

This common condition afflicts nine times more women than men. These persons are troubled by severe unrelenting pain in areas
where tendons join bone. Estrogen causes the deposition of fibrin, which can lead to impaired circulation with sludgy blood flow
in the areas of fibrin accumulation. Hyperestrogenemia is common in our modern world.

The etiology of fibromyalgia is complex and not completely understood at this time. A multitude of infectious organisms have
been found using high –resolution microscopy. The list of infectious pathogens identified in patients with fibromyalgia includes
mycoplasma, anerobic bacteria, several types of fungi, and borrelia burgdorfi (Bb). The fungi appear to play an important role in
causing endocrine dysfunction, presumably by the mechanism of releasing neurotoxic substances, into the bloodstream, which
disrupt the normal function of the hypothalamus producing hypothyroidism and hypo-adrenal function.

Several patients with fibromyalgia have recovered when taking the Japanese enzyme nattokinase made from fermented soybeans.
This improvement may have occurred because the enzymes are able to reverse the adverse effects of fibrin production and thus
improve the circulation of blood into fibrotic areas. Other enzyme products (Wobenzyme, Vitalzyme, Lumrokinase) might also
be valuable by the same mechanism.

Systemic Enzymes in Kidney Diseases

Acute and chronic glomerulonephritis are common kidney diseases. The patient with acute nephritis often has high blood
pressure, swelling of the extremities, and blood and protein in the urine. This disease is considered frequently to be the result of
an allergic reaction to the presence of streptococcal or other bacterial organisms in the body. Circulating immune antigen
antibody complexes are common, and if the disease does not soon spontaneously resolve, scarring and fibrin deposits in the
kidney‘s urine forming units (glomeruli) are found.

Chronic damage to the kidney in time may lead to uremia, dialysis, and kidney transplantation. The presence of fibrin deposits,
scarring of the kidney and circulating immune complexes makes a course of systemic enzyme therapy a good choice for these
patients. This therapy is safe and has good potential to be beneficial.

Other kidney diseases that could also be helped by systemic enzymes include Goodpasture‘s syndrome, Henoch-Schoenlein
purpura, Mixed cryoglobulinemia, IGA nephropathy, periarteritis nodosa, Wegener‘s granulomatosis, hemolytic uremic
syndrome, hypersensitivity vasculitis, interstitial nephritis (drugs may cause this---antibiotics like gentamycin, vancomycin,
amphotericin, etc., phenacetin, non-steroidal anti-inflammatory agents like naprosyn and indocin, and many chemotherapy drugs,
—or infection such as pyelonephritis).The pathology of swelling, inflammation and scarring(fibrosis) in all these conditions
could be helped by systemic enzymes.
Use of Enzymes in Trauma

Serious injuries are usually followed by massive swelling and considerable pain. Immediate therapy with enzymes can
dramatically shorten the disability and quickly resolve the pain. The key to this therapy is to take enough enzyme immediately as
the battle is being lost when swelling and pain appear. Rehabilitation and recovery will be delayed. It is far more effective to use
too much enzymes early than to have to frequently raise the enzyme dose because pain and swelling is spreading.

Lowering the enzyme dose is simple. This may call for using 15 to 20 capsules of systemic enzymes three times daily for injuries
such as severe auto accidents with multiple fractures, dislocated hips or shoulders and following knee and hip replacements. Most
likely the recovery period from joint replacement surgery could be significantly shortened if orthopedic surgeons used systemic
enzymes. Patients taking enzyme therapy should stop this therapy 24-36 hours prior to elective surgery and resume the therapy
24-36 hours after the operation. Taking enzymes during the immediate post-operative period could prevent the normal occlusion
by fibrin in small blood vessel lacerations, which might produce oozing of blood with anemia postoperatively. German surgeons
have effectively used enzymes in surgical patients for many years. Remember it is more effective to decrease the dosage when
things are going well than to increase the dose when pain and swelling have gained the upper hand. Large doses of enzymes do
not cause side effects.

My personal experience made me a believer in enzyme therapy. One of my molars needed a root canal, which I knew was
dangerous in my diabetic state as it always creates an abscess in the root canal tooth which can never be sterilized. The extraction
of the molar tooth was quite difficult as it required continuous effort by 2 dentists for 90 minutes. One of them later admitted it
was one of the most difficult extractions he had ever performed. Within an hour I began taking 900 mg of bromelain three times
daily (large dose). Neither pain or swelling appeared which surprised the dentist.

Enzymes and Estrogen Excess States (Fibrocystic Breasts, Fibroids of the Uterus, Endometriosis, Polycystic Ovaries,
Benign Prostatic Hypertrophy, Cancers of Breast, Prostate, Uterus, Ovary)

Estrogens are able to produce fibrosis, and this capability leads to these painful disorders.

Several factors are producing the estrogen excess status that is widespread in the developed world:

• Breakdown of petrochemicals, pesticides, herbicides, plastics, sodium lauryl sulphate from cosmetics, propylene glycol, vehicle
exhaust, and other agents into estrogenic substances in the human body.
• Extensive use of estrogenic hormones to expedite growth of cattle and chicken.
• Use of powerful pharmaceutical estrogens(Premarin) and oral contraceptive pills that magnify the existing estrogen excess in
the female body.
• Misuse of estrogens in therapy as a sole agent instead of combining natural estrogen with safe natural progesterone, which
nullifies the adverse effects of estrogen alone therapy.
• Diets high in sugar and dairy products, and low in fiber result in recycling estrogen into the body instead of elimination in the
stools which occurs on high dairy diets. These diets also interfere with proper production of progesterone by the corpus luteum of
the ovary.

Because of this state of estrogen excess, fibrosis, and painful cysts appear in breast tissue(fibrocystic disease of the breast). Many
women cease ovulation 10 or more years before menopause due to this estrogen excess state. These women are thus unable to
benefit from the estrogen ameliorating effects of progesterone production by the corpus luteum. The heavy intractable bleeding
they experience often leads to hysterectomy. Existing fibroids in the uterus tend to appear and steadily enlarge under the
stimulation of excessive amounts of estrogen.

Many women suffer from endometriosis, which seems to be produced by retrograde flow of blood into the peritoneal cavity at the
time of menstruation. This fluid entering the peritoneal cavity contains blood and shed endometrial cells. A profound
inflammatory reaction appears which often results in severe pain. Recurring episodes of this problem leads to ―chocolate cysts‖
and scarring at the site of these peritoneal deposits. An unfortunate result of endometriosis is scarring of the fallopian tubes and
sterility. The patient with endometriosis might need 5 or more capsules of enzymes three times daily until their pain disappears.
Some women can ascertain when menstruation is imminent. These women could possibly be helped by starting enzymes before
they notice the onset of menstrual pain.

Enzyme therapy can stop the development and enlargement of existing uterine fibroids. Patients with fibrocystic breast disease
and enlarging fibroids should stay on enough enzyme therapy to prevent symptoms. Whether high doses of enzyme therapy over
prolonged periods of time could completely dissolve large fibroids is not known, but it might well do so and appears to be worth
a trial.

Another worthwhile approach to estrogen excess uses enzymes (DeAromatase[1]) which effectively corrects this problem by
blocking the actions of the enzymes aromatase and 5 alpha reductase so that estradiol, testosterone and progesterone levels return
to normal. Without this enzyme therapy androstenedione and testosterone are steadily converted into estrogen (estradiol). This
raises already elevated levels of estradiol and diminishes already low levels of testosterone. To make matters even worse the
enzyme 5 alpha reductase at the same time is converting testosterone into di-hydrotestosterone the substance believed to be
responsible for some prostate gland enlargement.
When DeAromatase therapy comes on the scene progesterone begins to inhibit the action on 5 alpha reductase causing rising
testosterone levels and reducing the amount of estrogen formed.
Both testosterone and progesterone promote the p53 gene leading to normal healthy cell death (apoptosis) while estradiol
promotes the Bel 2 oncogene which blocks normal apoptosis (cellular death) and causes cancer.

Arteriosclerosis and Enzyme Therapy

One of the potentially most useful areas for enzymes is in stopping the progression, and hopefully promoting regression of
arteriosclerotic plaques. Excessive clotting caused by infectious inflammatory reactions in the body is now believed to play an
important role in the causation of arteriosclerosis. This can be reversed by the fibrin lysis occurring during enzyme therapy.
Three cases illustrating clear improvement in arteriosclerotic symptoms after enzyme therapy are presented later in this article.

Keloids

Some patients develop thick unsightly scars(keloida) after surgery or injuries. Taking systemic enzymes following the surgery
can prevent this excessive scar formation. Knowledgeable plastic surgeons use enzymes to minimize scar formation after surgery.

Case Reports

Case 1 A patient with a hip defect had considerable pain and difficulty walking. After starting serrapeptase he became completely
pain free and walked in a normal fashion for the first time in years.

Case 2 A 34-year old male had a bad family history for vascular disease(three grandparents died of vascular disease at 56. 56, and
63 years of age, and his mother died of a heart attack at age 62). This patient took a prolonged course of intravenous chelation
along with measures to correct arterial disease (high dosage vitamin C). He then had an ultrasound study of his carotid arteries ,
which revealed 12% narrowing of the right carotid artery and 14% narrowing of the left carotid artery. The site where the right
carotid artery bifurcates into two arteries had a 24% narrowing. He increased his vitamin C dosage to 10-12 grams daily, started
taking 1.5 grams of lysine three times daily, and also took folic acid, B12 sublingually, twice daily, B6, and trimethylglycine.
Serrapeptase 10 mg twice daily was begun. A repeat carotid artery study in 18 months disclosed complete resolution of all
plaques in the carotid arteries. Vitamin K2 45 mcg. daily which removes calcium from arteries and moves it into bones would
probably also have been a worthwhile therapy.

Case 3 In 1945, a six year old child and a friend fell into a pocket of radioactivity (about 650,000 millicuries of Iodine 131
exposure) while playing a game. He immediately noticed burning in his lungs and trouble breathing. His friend died within a few
months. And the girl who pulled him out of the hole died of the effects of radioactivity at age 35. He developed severe dyspnea
with any exertion along with wheezing and scarring of his lungs and other organs.

At age 63, a knowledgeable physician urged him to take Vitalzym as, ―It will dissolve the scar tissue.‖ His pulmonary function
improved by 25% and he can now climb two flights of stairs without difficulty.

Case 4 A man with severe angina and claudication was not improved by laser therapy, robotic therapy, or endarterectomies of his
coronary arteries. Therapy with ozone saunas and calcium EDTA chelation relieved his symptoms, but with exertion he still had
problems. After a few days of Vitazlym, along with ozone saunas and chelation he was able to resume hunting. fishing, and
hiking without any pain in his chest or legs.

Case 5 A man with angina at rest and claudication after walking 15 feet improved with calcium EDTA and ozone saunas. Within
2 days on Vitalzym he was able to walk to the grocery store without stopping or having either chest or leg pain.

Case 6 This woman had temporo-mandibular joint pain for several years with no response to laser surgery surgery, physical
therapy, or acupuncture. Sleeping and eating were impaired due to pain. After two months of Vitalzym, she was pain free and
much improved.

Case 7 This mother had her 18 month old son do a back flip onto her nose and the back of his head. smashed her nose. She was in
severe pain with immediate swelling of her nose, cheeks, and eyes. She placed an ice pack on her face and took 20 Vitalzym. The
swelling began to disappear and the pain was nearly gone by the following morning. After 10 more Vitalzym capsules the next
morning, the pain and swelling disappeared.
Hospital Formularies and Systemic Enzymes

Because systemic enzyme therapy was developed in Europe and the Far East, most US physicians are certainly unfamiliar with it.
This means that patients landing in hospitals with some of these previously discussed problems may find themselves in an
institution that does not stock systemic enzymes. Hospital formularies lean heavily toward pharmaceutical drugs, so the systemic
enzymes may not be in the formulary unless unless the hospital is staffed by some knowledgeable plastic surgeons. Furthermore,
hospital formularies do not like to stock a product that will be used by only one patient as unused portions of the product may
expire. Even without the availability of enzymes in the formulary, some hospitals will permit patients to take outside therapy if
the attending physician gives his or her approval.

In reviewing the available literature about enzyme therapy, it is apparent that not all patients improve. Most studies show 75-80%
of patients clearly improve. This raises a very important question. Would higher doses over a longer time frame have benefited
those patients who failed to respond to the initial enzyme dosage?

The safety of systemic enzymes in high dosages means that we cannot be certain systemic enzymes would not help a patient until
high doses have been tried over longer periods of time. It appears to me that this is particularly relevant in diseases like
sarcoidosis, pulmonary fibrosis, scleroderma and uterine fibroids where there is such extensive scarring it would not be
reasonable to expect prompt resolution. There is a possibility that severe scarring may not be reversible, but this needs to be
proven as reversal of scarring in these serious health problems could be of immense value to the afflicted patients.

Practical Aspects of Enzyme Therapy

Tylenol(acetaminophen) is a very dangerous drug that, in my opinion, should never have been released. This drug is nearly
universally found in US homes. Acetaminophen accelerates aging and can cause death from acute necrosis of the liver in young
healthy persons who use this drug because of an acute viral infection. None of us needs speeding up of the aging process.
Enzymes are far safer than this therapy for pain.

Having Lumbrokinase, Nattokinase, Wobenzyme, Bromelain or Vitazym+ in your home provides a therapy well qualified to
alleviate a wide variety of painful disorders without any danger .to the user. The usage of enzyme therapy should increase as
more health care practitioners learn about this exciting therapy.

Treating Diabetes With Enzymes: What We Know Now

Up to a year ago, for anyone asking if systemic enzymes could help lessen the load of troubles that beset Type 1 diabetic patients,
I would have told them about lowering pancreatic inflammation, and possibly helping with lower extremity circulatory issues. I
would have never suggested that the use of enzymes could decrease the need for insulin, increase energy or reverse the seemingly
myriad of things diabetics suffer from. Then we started getting information from Type 1 patients that amazed even me and that
have subsequently sparked new research. Here are two typical case histories.

Case History #1:

A Type 1 diabetic Native American patient from Montana in his mid 40's, very insulin dependent, with peripheral neuropathy in
the lower extremities (LE's) and presenting paresthesia as well in the upper extremities (UE's) radiating distally to the hand.
Peripheral Vascular Disease (PVD) in the LE's had already caused several toes to be amputated.

Patient began taking therapeutic doses of fibrinolytic systemic enzymes. Within weeks, circulation was opened in his feet and
lower extremities. Skin there returned to a pink / flesh color. Remaining toes now have full circulation and are no longer
candidates for amputation. Lower extremity and upper extremity pain became paresthesia (tingling and pins and needles), and as
a result is much more bearable.

The patient‘s insulin needs were decreased.

Case History #2:

86-year-old male Caucasian from Las Vegas history of Type 1 Diabetes for over 50 years. One below the knee amputation (left
side) already done due to DVP, the other leg about to be amputated due to general lack of blood flow and arterial blockage. Poor
circulation body wide and a gray / white pallor to the skin also body wide. Neurological pain was had at both lower extremities.
Urine flow beginning to flag as patients kidneys became laden with scar tissue (Glomerulosclerosis). Patient was highly insulin
dependent. Above that the patient was functionally blind in one eye from a Lasix procedure that had generated scar tissue over
the retina.
After several weeks of systemic enzyme use the patient first noticed a lessening in his lower extremity neurological pain
(neuropathy). His skin color in the remaining leg changed to rosy as circulatory pathways were opening. Outer layer of whitish
dead skin shed off leaving what resembled a ―body wide dandruff‖, exposing new pink /flesh tone skin beneath. The existing leg
became pink with blood flow, no longer ulcered, no longer had ischemic pain and was saved from amputation.

Urine flow increased as fibrin was lysed (eaten away) from the kidneys. If the urine was allowed to stand in the toilet a layer of
tiny bits of fibrin (component of scar tissue) in what resembled fiberglass floated to the top. The fibrosis that had blinded one eye
was lysed away and the patient now has better than 20/20 vision in that eye. Most significantly, the patients own insulin
production has returned (thought to be impossible under the auto immune theory of diabetic pancreatic destruction). He is no
longer insulin dependent. After medical testing the patient is no longer considered diabetic at all and is off all medication.

Sound fantastic? It did to me, even as a Naturopath who expects nature to do fantastic things. Diabetes is one of those diseases
you never expect patients to get better from. Even after several years of working with systemic enzymes I had heard of some
Type 2 patients improving their energy and leveling off their sugar highs and lows but I had never expected any form of
improvement in Type 1 patients, the medical literature was very clear. Once the immune system destroyed the insulin producing
portions of the pancreas, there was no getting those tissues to function again! That medical ―truth‖ has turned out to be merely a
medical theory.

Lets take a look at the present understanding of the root causes of diabetes and add our own conjectures based on what we have
observed clinically. We know from the present research work being done that the root cause of diabetes is inflammation of the
pancreas. How and why this inflammation sets in we yet do not know. As we also know from the physiology of trauma,
inflammation breeds fibrosis or scar tissue. One follows a chronic course of the other.

Fibrosis is also the culprit in the Peripheral Vascular Disease. In this condition, fibrin plugs form in the micro circulation (tiny
blood vessels) forming blockages to full blood flow. Fibrin also forms the matrix for arterial plaque. Inflammation of trauma to
the inner lining of an artery (intima), causes the traumatized or weakened section to shore itself up with scar tissue. On the spider
web of scar tissue fat, calcium and heavy metals accrue forming what we know as arterial plaque. Once the fibrosis blockages
become extensive enough, the patient presents the signs of PVD, which are cold extremities, intermittent caludication (pain on
walking from lack of oxygen supply to the tissues known as ischemia), non healing ulcerations of the skin and eventual death of
tissue creating gangrene leading to amputation.

The high blood sugar levels had during diabetes damages the body‘s organs. One of the first organs to be damaged are the nerves
to the legs and then the arms. Wherever the circulation is poorest the nerve damage follows and radiating nerve pain is had
(neuropathy). The damage begins with, you guessed it, inflammation and progresses with, you guessed it again, fibrosis. It is
this inflammation into fibrosis that seems to be a recurring theme in diabetes.

For a moment lets do some education on orally administered systemic enzymes. They have a 5 decade history of wide spread
medical use in Germany, Central Europe and Japan with over 150 million patients in Europe alone having undergone enzyme
therapy in the last 4 decades. There are over 200 peer-reviewed studies proving the absorption, therapeutic action and total lack
of toxicity (no LD-50) of systemic enzymes. Their primary action is anti-inflammatory, (though not through a COX 1 or Cox 2
action. The enzymes instead ―eat‖ pro inflammatory cytokines). The enzymes also have a proven lysing action on all types of
fibrosis and scar tissue leaving normal or endogenous tissue entirely intact and un-bothered. This is due to the body ―tagging‖
excesses of fibrin as exogenous proteins. (The subject of protein tagging and its discoverer won the Nobel Prize in biology in the
late '90's). Entering the key words: systemic enzyme, serrapeptase, nattokinase, bromelain, pancreatin, papain, trypsin, chymo
trypsin into the search engine at Pub Med will bring up some of the current research on systemic enzymes and their applications.
A search in the ―medical fields‖ section of www.mucos.cz will show abstracts of the extensive older research done with the first
systemic enzyme blends of the 50's and 60's. It has to be said that there is nothing, no drug or substance, in either the allopathic
medical world or in the natural health world that can remove scar tissue but highly fibrinolytic systemic enzymes.

Current thinking on diabetes is that the body‘s immune system attacks the pancreas creating inflammation. This may be so.
Further, the current thinking is that the inflammation brings about the destruction of the Islets of Langerhans and its Beta Cells,
the places where insulin is made. This may not be so. If the studies that are currently being planned and executed further
demonstrate what we are seeing clinically with Type 1 patients on systemic enzymes, then this point will have to be re-thought.
Clinically most of the Type 1 patients have a significantly lower need for insulin while some no longer need the insulin at all.
This would suggest that the Beta Cells and the Islets are not destroyed. I conjecture that they are merely clogged by the fibrosis
created by the inflammation. Once the causative inflammation is reduced and once the fibrinolytic action of the enzymes has
eaten away the fibrosis and reopened the channels, then what ever production the Islets can make can actually get into the system.

I believe that the global (body wide) non-toxic, anti-inflammatory effects of highly fibrinolytic systemic enzymes and the scar
tissue eating effects of the same enzymes are the reasons we are seeing the decrease in pancreatic inflammation, decrease in
diabetic neuropathy, in it's associated Peripheral Vascular Disease, and the decrease in insulin dependence we are seeing
clinically in Type 1 patients. Let's see if the research further verifies the observed findings and gives us more insight into the
pathways of action.

Enzyme Therapy for Autism

The pounding went on all day and all night. My son was a chronic head-banger from early on. Our efforts to help him resolve this
and other debilitating problems, such as extreme sensory sensitivities and socialization difficulties, led us down many roads.
Enzymes provided one of the key paths.

In the past five years, enzyme therapy has emerged as one of the most successful treatments for autism-related conditions, based
on a new understanding about how closely the digestive, nervous, and immune systems function together and on how to use
specific enzymes. Since taking them, my older son, who was diagnosed with an autism spectrum condition (ASC), no longer
bangs his head on the floor 10 to 14 hours a day. He now interacts with others around him and communicates well. His sleep and
sensory problems have also improved. The rest of us took enzymes as well, and my younger son‘s reflux and bowel problems
faded away and my chronic migraines disappeared.

My family isn‘t the only one to experience these outcomes. After tracking results for more than five years, I‘ve found that 90 to
93 percent of people with ASC see improvements after trying a good-quality enzyme product. Benefits appear in a wide range of
behavior, language, cognitive, and physical issues, and older children and adults experience these benefits as much as younger
kids.

Food Intolerances and Allergies

Autistic children often suffer from numerous kinds of food intolerances and digestive problems. My son was so sensitive to dairy,
he would begin banging his head hard on the floor about three hours after eating it. While this reaction occurred with other foods
and stimuli, we knew that dairy was a specific trigger. To resolve it we found a product containing several proteases including
one known as DPP IV, which breaks down dairy and gluten proteins.

Unlike many drug therapies, enzymes are a quick and relatively inexpensive option to try, with a high probability for success.
You will usually see results within the first four weeks, and often with just one bottle. While we found success by focusing on
specific enzymes, some ACS children respond equally well to a broad-spectrum enzyme product that focuses on the digestion of
carbohydrates and fats in addition to proteins. As you plan out a course of enzyme therapy, think in terms of categories: Children
who have trouble digesting proteins need proteases; amylases break down carbohydrates; problems with candida yeast respond
well to fiber digesting enzymes; and those with dairy intolerance benefit from lactase and DPP IV enzymes. Ascertain which
category applies best to your child‘s particular problem and then choose among the enzyme products within this category. Most
families with children who have developmental delays tend to get best results using one of the broad-spectrum products at all
meals along with one of the strong protease products.

The Bug Connection

Many children with autism related conditions also suffer from candida yeast or bacterial overgrowth in the gut. To resolve the
problem try yeast-targeting products with high levels of fiber-digesting enzymes (like cellulases) to break down the outer walls of
yeast cells. The product should also contain a high level of proteases to help clear out pathogenic yeast and reduce any die-off
reactions. Consider combining a yeast-controlling herbal supplement such as grapefruit seed extract or oregano with the enzymes
for a synergistic effect.

Underlying persistent viral infections also seem prevalent in autistic children, and when these are addressed, the children show
some permanent improvements in language, socialization, behavior, and cognitive ability. Several autism specialists are turning
to Valtrex, a prescription antiviral medication that provides good results. Another alternative, ViraStop, is a specialty blend of
enzymes used between meals at high therapeutic doses (12 to 15 capsules per day). Two preliminary investigations using
ViraStop resulted in a program that has delivered excellent results. Combining this with other supplements that have antiviral
properties, such as olive leaf extract, vitamin C, or monolaurin, increases its effectiveness against viruses.
How Enzymes Therapy Cures Allergies

Lots of individuals in the United States are allergic. Out of these, numerous amounts are afflicted with food allergies and
breathing allergies. Men and women that have problems with food allergies struggle to remedy their own issue because they are
unaware which food item has really prompted the allergic attack. In addition, they mix up food intolerance to allergies. In
addition they attempt various treatment options to take care of their situation but don‘t obtain the expected results. What these
people don‘t know is food allergies can be simply cured with the assistance of enzymes therapy. Right here, we‘re going to look
into how enzymes therapy may be beneficial in eliminating food allergies.
Enzymes therapy is generally a procedure whereby enzymes are infused within the body to eradicate medical conditions. The
enzymes any time implanted within the body increase the biological processes in the body and enhance the gastrointestinal
system. Enzymes enhance the growth of healthier intestinal flora. This thus stimulates your immune activity and also elevates
your own body‘s immune system. Systemic enzyme therapy will help with decreasing inflammation, helps blood flow in the
body, assures sufficient flow of nutrients to the whole body plus assists with flushing out the toxic substances out of your body
that may trigger various ailments including allergies.

How enzymes therapy will work in treating allergies

Enzymes hinder the process, which causes allergy symptoms by deteriorating the protein allergens within the body. Regarding
food allergies, whereby there‘s very low creation of enzymes within the body, enzyme therapy elevates your body‘s pancreatic
enzymes. Consequently, enzymes therapy is generally known as an helpful cure for food allergies.

Enzymes therapy in treating food allergies

Allergies, especially food allergies can be simply remedied with the aid of enzymes therapy. Quite often it happens that lots of
individuals mix up food intolerance with food allergy. However, enzyme therapy aids you to eliminate both. If you wish to
eliminate your food allergy through enzymes therapy then all you‘ve got to do is use the appropriate enzyme with the food which
results in allergy. Should you be having troubles digesting the different nutrients then you‘ll definitely have to take the following
enzymes to get rid ofyour food allergies.

• Amylase or Amyiolytic Enzyme for Carbohydrates

• Proteolytic or Protease Enzyme for Proteins
• Lipase or Lipolytic Enzyme for Fats

Other than these, you‘ll find that you have to take an enzyme referred to as lactase to assist in the processing of dairy foods and
also lactose should you be intolerant to lactose. For anyone who is having issues while consuming foods like vegetables and
beans you may take the enzyme alpha-galactosidase.

Should you be not aware in regards to what food item causes food allergies then it is advised that you simply take a mixture of all
enzymes, including amylase, lipase and protease enzymes. The best way to make these enzymes effective is by consuming these
enzymes half an hour before having your meal or even after your meals whenever you really feel it is convenient for you
personally and would certainly help make it easy for you to break down the food and would likely help you to reduce the
allergies signs and symptoms.
Even though enzyme therapy is one of the recommended treatments for allergies, it will always be advisable that you confer with
your doctor before going through any kind of enzyme therapy for allergies. This is particularly crucial in the event of food
allergies because consuming any kind of food that the person is allergic to mainly because infusing enzymes can only worsen the
problem of the person.
Enzymes Used for Treatment in Digestive Disorders

Enzymes show benefits in more areas than just food production; enzymes commonly act as a treatment for many digestive
disorders. Many digestive orders occur because the human body lacks the ability to digest or breakdown certain things found in
many common foods. Enzymes are a popular treatment for these conditions because enzymes act on the intolerable food to
change it into something more digestible. This makes enzymes a possible treatment for common digestive ailments such as celiac
disease and lactose intolerance.
Celiac disease, a digestive disorder, causes an allergic reaction to gluten. This prohibits people with the disease to consume foods
with the gluten protein in them. Papain, a proteolytic enzyme, helps those who suffer from celiac disease by breaking down
gluten (Roxas 312). This allows the celiac to consume foods with gluten without suffering from bowel trouble. Proteolytic
enzymes prove to be beneficial supplements for those who have trouble processing gluten, and they are becoming a common
dietary recommendation for people with this condition.

Lactose intolerance causes many people to refrain from eating all types of dairy products, but an enzyme known as lactase shows
proof that it helps rectify the problems caused by this disorder. Lactose intolerance primarily occurs when a person produces less
lactase than needed to breakdown lactose. Taking the enzyme lactase orally results in increased tolerance of lactose and lactose
containing foods (Roxas 311). This dietary supplement improves digestive problems associated with lactose intolerance such as
cramping, bloating, and diarrhea. This enzyme helps those with lactose intolerance to maintain health while ingesting lactose.

Enzymes play a large role in many areas of our lives. Enzymes are found in plants, animals, the food we eat, and ourselves.
Enzymes change the simplest things such as the flavor of cheese, freshness of bread, and clarity of fruit juice. Enzymes also aid
in digestive problems that many people suffer from all their lives. The benefit of enzymes to the world is reflected in our
everyday lives, but it is commonly overlook.

Enzyme replacement therapy for pancreatic insufficiency: present and future

Abstract

Pancreatic enzyme replacement therapy is currently the mainstay of treatment for nutrient malabsorption secondary to pancreatic
insufficiency. This treatment is safe and has few side effects. Data demonstrate efficacy in reducing steatorrhea and fat
malabsorption. Effective therapy has been limited by the ability to replicate the physiologic process of enzyme delivery to the
appropriate site, in general the duodenum, at the appropriate time. The challenges include enzyme destruction in the stomach,
lack of adequate mixing with the chyme in the duodenum, and failing to deliver and activate at the appropriate time. Treatment is
begun when clinically significant malabsorption occurs resulting in steatorrhea and weight loss. Treatment failure is addressed in
a sequential fashion. Current research is aimed at studying new enzymes and delivery systems to improve the efficiency of action
in the duodenum along with developing better means to monitor therapy.

Introduction

Normal pancreatic function ensures effective digestion and absorption of nutrients. Clinical exocrine pancreatic insufficiency
occurs when secretions of the pancreas do not maintain normal digestive function, resulting in nutrient malabsorption and other
symptoms such as diarrhea, which in turn affect quality of life and eventually result in malnutrition.1–3 The leading cause of
pancreatic insufficiency is chronic pancreatitis, which is estimated to affect 0.4% to 5% of the world population.4 In children,
however, the most common cause of pancreatic insufficiency is cystic fibrosis. The reported prevalence of exocrine pancreatic
insufficiency in chronic pancreatitis and cystic fibrosis is 30% to 40% and 80% to 90% respectively.5 The use of oral therapy
pre-dates the creation of the US Food and Drug Administration (FDA) in 1938, and currently enzyme replacement is the
mainstay of therapy in patients diagnosed with malabsorption secondary to pancreatic insufficiency.

In order to manage patients effectively with malabsorption related to exocrine pancreatic insufficiency, an understanding of
normal pancreatic physiology and pathophysiology is required. This review provides an overview of normal pancreatic function
and the biochemistry of lipid digestion, along with the pathophysiologic mechanisms of disease that lead to malabsorption.
Enzyme replacement therapy is reviewed including the pharmacokinetics, various preparations, dosing, and side effects. The
inadequacy of current therapy has led to ongoing research, which is reviewed in detail to examine how this has improved our
understanding of lipid digestion and also the therapy we have to offer.

Normal exocrine pancreatic physiology

Composition and regulation of pancreatic fluid secretion

The exocrine pancreas plays a key role in the digestive function through the secretion of pancreatic juice consisting of numerous
enzymes and of aqueous solution rich in sodium bicarbonate. Postprandial secretion can increase up to 1 to 2 L per day.6–8 Three
main types of enzymes are secreted to digest the ingested macronutrients: proteins (trypsinogen 1, 2, and 3, chymotrypsinogen,
proelastase 1 and 2, protease E, kallikreinogen, procarboxypeptidase A1, A2, B1, and B2), starchy foods (α-amylase), and lipids.
While lipases and amylase are secreted in the active form, proteases are secreted as pro-enzymes. Trypsinogen is converted to its
active form trypsin in the duodenum by enterokinase, a protease secreted by the enterocytes, and trypsin in turn activates the
other pancreatic proteases.

Human pancreatic enzymes involved in lipid digestion

Enzyme content of pancreatic fluid changes according to different factors including age, gender, and diet. The pancreas reaches
mature function by 2 years of age,22 and enzyme secretion is lower in full-term newborns and young infants than in adults.22–25
Pancreatic secretion in the elderly is decreased, with as little as 56% of young adult function maintained, but the clinical impact is
controversial.26,27 Men may have higher levels of secretion than women but the physiological relevance is not documented.27
Pancreatic fluid composition varies highly among individuals.7,28–31 Amount and type of lipids consumed might explain in part
this individual variability. Indeed, a 2-week high-fat/low-carbohydrate diet is associated with a 4-fold higher pancreatic enzyme
output in healthy humans compared with a diet rich in carbohydrates or proteins.32 Pancreatic lipase levels in the human
duodenum vary with the quantity and the type of lipids ingested during a single meal.29,30,33–36 The rate of pancreatic enzyme
degradation in the small intestinal lumen also varies among individuals.37 As a result of these variables, determining the exact
enzyme level secreted by the normal human pancreas is difficult. Furthermore, varying methods used for collection and
measurement of activity result in data that are not directly comparable. Pancreatic or duodenal juice is collected using solid or
liquid meal,7,24,28,30,31,34–36,38,39 or after direct hormonal stimulation8,22,23,40,41 or through baseline.24,39,42,43
Enzyme activity measurements are in general done under optimized assay conditions and do not indicate the real activity in
vivo.28,38 Data are available as enzyme activities or output expressed as Units (U) per minute or U per hour, U per milliliter, or
as milligrams of secreted enzymes (Tables 2 and and33).7,8,22–24,29–31,34–36,40–45 To make the comparisons easier, enzyme
activities are generally expressed as International Units (IU). One IU is defined as the amount of enzyme required to release 1
μmole of product from the used substrate per mL per min under the standard assay conditions.

There is a specific orchestration of the pancreatic fluid secretion during the fed state leading to appropriate enzyme delivery on
demand in the duodenum. During the cephalic phase, orosensory perception of lipids seems to increase pancreatic secretion.46–
49 During the gastric phase, digestion of proteins by pepsin and of triglycerides by gastric lipase generates amino acids and free
fatty acids, respectively.50,51 When delivered through the pylorus, they become powerful stimulants of the cholecystokinin
hormone (CCK) produced by the duodenal endocrine cells which stimulates pancreatic enzymes secretion and controls the gastric
emptying rate.49 The acidic pH of the chyme entering the duodenum stimulates the release of secretin, which increases the
secretion of water and bicarbonate ions from the pancreas.49 This gastric phase of digestion represents an important aspect in the
overall postprandial regulation of pancreatic secretion that becomes abnormal after gastric surgery when gastric digestion and
emptying are altered.52,53 During the intestinal phase, enterohormones, such as CCK, together with neurotransmitters and
neuropeptides further stimulate pancreatic secretion.49,54 Thus, digestive pancreatic enzyme response to a meal follows a
specific pattern in which the degree and duration depend on nutrient composition, caloric content, and physical properties of the
meal through hormonal and neural regulations; enzyme secretion into the duodenum increases quickly reaching peak output
within the first 20 to 60 minutes postprandially, then decreasing to a stable level before reaching an interdigestive level at the end
of the digestive period, ie, about 4 hours after meal intake.27

Role of pancreatic enzymes in lipid bioavailability

Pancreatic juice plays a key role in the digestion of all macronutrients, but is most crucial for lipid digestion. Protein digestion
begins in the stomach with the concomitant action of hydrochloric acid and pepsin, continues with pancreatic proteases in the
duodenum, and finishes with numerous brush border peptidases located all over the small intestine.50 Starch digestion begins in
the mouth with salivary amylase, continues with pancreatic amylase, and ends with several intestinal brush border
oligosaccharidases.50 In contrast, the majority of lipid digestion and absorption occurs between the pylorus and the ligament of
Treitz. Prior to this step, 5% to 40% of the dietary triglyceride acyl chains are released in the stomach by gastric
lipase,29,30,34,51,55,56 which continues its action in the duodenum together with pancreatic lipase until these enzymes are
degraded by pancreatic proteases.34 The human pancreatic lipase (HPL) specifically cleaves the outer sn-1 and sn-3 esters on the
triglyceride molecules and generates two free fatty acids and a 2-monoglyceride.10,19 This lipase needs a specific cofactor,
colipase, to anchor at the lipid–droplet surface containing phospholipids and surrounded by bile lipids (bile salts and
phospholipids).16,58 Although a pH of 8 to 9 appears to be optimal for this lipase activity in vitro, bile salts allow the enzyme to
work efficiently at a pH of 6 to 6.5 in vivo.10,29,35 HPL is responsible for the hydrolysis of 40% to 70% of
triglycerides.29,30,34 The pancreatic lipase related 1 protein (hPLRP1) has no known lipolytic activity11,12,16 but inhibits to
some extent lipolysis of milk triglycerides by HPL.9 The pancreatic lipase-related 2 protein (hPLRP2) exhibits a broad substrate
specificity hydrolyzing milk triglycerides in a synergistic effect with HPL,9 phospholipids,15,16,19 galactolipids,13,18 and
esters of lipid-soluble vitamins.17 Carboxyl ester lipase (CEL) (also secreted by mammary gland cells as bile salt-stimulated
lipase, (BSSL)) will hydrolyze triglycerides, diglycerides, phospholipids, and esters of lipid-soluble vitamins and of
cholesterol.14 Of note, hPLRP2, which is highly expressed in early life, plays an important role in lipid digestion in infants fed
human milk,59,60 along with BSSL.59 Phospholipase A2 hydrolyzes phospholipids to lysophospholipids20 which is essential for
an optimal absorption of lipid nutrients.61 Products generated during lipolysis are solubilized in bile salts–mixed micelles and
liposomes (vesicles) which allow absorption across the intestinal villi.62 Once absorbed, the digested lipids are converted back to
triglycerides, phospholipids, and esters of cholesterol and of lipid-soluble vitamins, then packaged as chylomicrons and
transported through the thoracic duct into the systemic circulation for delivery to various sites throughout the body.61,63

Exocrine pancreatic insufficiency

Clinical presentation and diagnosis

Exocrine pancreatic insufficiency (EPI) is largely a clinical diagnosis. A patient with a known cause of pancreatic insufficiency
who presents with weight loss and fatty diarrhea is usually begun on treatment without extensive testing. As up to 20% of
patients with chronic pancreatitis resulting in insufficiency will present with no history of pain suggestive of pancreatitis,
steatorrhea may be the presenting complaint.64 The diagnostic options include indirect measures (ie, 72-hour fecal fat and fecal
elastase) or direct measures (ie, secretin–cerulein or secretin–pancreozymin tests). Steatorrhea is classically defined as at least 7 g
of fecal fat over 24 hours, in the context of a 72-hour stool test while on 100 g of fat daily;65 however, quantification of fecal fat
is inconvenient and difficult. With reasonable clinical suspicion, a positive spot stool test may be adequate to detect steatorrhea66
but will not allow monitoring of response to therapy. Fecal elastase testing may be used to demonstrate a lack of endogenous
enzyme. It has been found that fecal elastase is 72% sensitive for severe pancreatic insufficiency and 90% specific. It does have
lower sensitivity with milder steatorrhea, and is not as useful in diabetics, as fecal elastase decreases with increased duration of
diabetes.67–69 In contrast to the above indirect measurements of pancreatic function, direct measurements with the secretin–
cerulein or secretin–pancreozymin tests are the gold standard for accurate assessment of the exocrine function of the
pancreas.69,70 However, the limitations of the direct functional tests are that they are usually performed only at specialized
centers, and they are time consuming and expensive.69

Patients usually will present for evaluation when <10% of exocrine pancreatic function remains, which results in lipid
malabsorption.3,71 Steatorrhea (frothy, foul smelling, buoyant stools), weight loss, abdominal discomfort, and abdominal
swelling are the common presenting symptoms and are related to the inadequate lipid digestion. Even with significant pancreatic
insufficiency, protein and starch digestion are usually maintained at a normal physiologic level. However, once pancreatic
insufficiency progresses, lipid malabsorption becomes the overriding problem and cause of many of the clinical symptoms and
nutritional deficiencies. Consequences of abnormal lipid digestion lead to malnutrition, with malabsorption of lipid-soluble
vitamins (A, D, E, K), depleted micronutrients, and decreased circulating lipoproteins.3,72–74 Exocrine pancreatic insufficiency
itself can cause or exacerbate motility disorders. There are alterations in neurohormonal regulation in gastrointestinal motility;
specifically, the production of CCK and of pancreatic polypeptide are adversely affected by undigested food in the intestines,
which can lead to rapid gastric emptying and altered antroduodenal and gallbladder motility. In untreated EPI, patients are noted
to have shorter fed patterns, and a faster small intestinal transit that is largely reversed with enzyme therapy.71 The severity of
such motility disorders is often related to the severity of the pancreatic insufficiency, and this can often be corrected with enzyme
replacement therapy.

Causes of lipid maldigestion and malabsorption

There are various causes of pancreatic insufficiency resulting in malabsorption (Table 4), and for some the status of pancreatic
enzyme levels has been documented (Table 5).23,24,35,40,42,44,45,71 Chronic pancreatitis (CP) and cystic fibrosis (CF) are the
most common causes of irreversible pancreatic insufficiency. Diabetes may also result in exocrine insufficiency.81 In contrast,
decreased production of pancreatic lipase without glandular destruction is associated with Celiac sprue, Crohn‘s disease, and
Shwachman–Diamond syndrome.2,71 Reversible pancreatic insufficiency has been reported in premature infants due to
developmental immaturity.22–25 The pancreas will gain complete function in infants at 2 years of age.22 Other causes of lipid
maldigestion are blockage of the pancreatic duct, and surgical resection.2,5,71

Motility disorders that result in rapid gastric emptying and decreased small intestinal transit time may also be associated with
malabsorption due to inadequate lipid digestion. Rapid transit causes poor mixing of food together with bile and pancreatic
enzymes, further reduces contact time with the small intestine leading to impaired digestion and absorption, and affects the
stimulation of pancreatic function.5,71 For instance, gastrectomy alters gastric emptying, which reduces lipase production
because chyme rapidly bypasses the duodenum resulting in reduced stimulation of duodenal hormones that normally stimulate
the pancreas to release enzymes.5 Of note, some studies of steatorrhea after gastrectomy have not demonstrated a benefit of
pancreatic enzyme supplementation.82

It is also important to be aware that diabetic patients may also suffer from exocrine insufficiency as a result of endocrine failure,
presenting as either classic steatorrhea or more subtly as brittle diabetes.81 Studies have reported that exocrine dysfunction
occurs in up to 43% of insulin-dependent diabetics, but its severity is typically mild to moderate, and only 1% of these patients
require therapy.83,84 Mild to moderate exocrine insufficiency was reported in 30% of type 2 diabetics, 19% of whom were
suffering from severe insufficiency.85 These studies raised the question of the clinical significance of EPI in diabetic patients,
which would potentially raise health care costs to these patients if expensive enzyme replacement therapy were required. A
thorough investigation studied pancreatic function in type 1 diabetic patients with a secretin–cerulein test, fecal fat stimulation,
and 2 fecal elastase tests to determine the accuracy of previous studies and define the clinical significance. In this study, 33% of
type 1 diabetics were found to have mild to moderate pancreatic insufficiency, but none of the patients had lipase levels <10% of
normal, which would necessitate enzyme replacement. It was concluded that fecal elastase or fecal fat levels were not reliable
diagnostic tools for diabetes. Moreover, the majority of these patients had steatorrhea not related to pancreatic function, but rather
to bacterial overgrowth.69 Although diarrhea and steatorrhea are often multifactorial in diabetics, and the significance of
exocrine insufficiency in diabetics is still under study, physicians should be aware of the association and have a low threshold to
test for this entity in diabetics.81

The pathophysiology of EPI caused by glandular destruction in CP and CF

Irreversible pancreatic insufficiency is mainly observed in CP and CF.4,5 In CP, long-standing inflammation with fibrosis results
in destruction of acinar cells. A variety of proposed pathogenic mechanisms has been described. Alcohol is a common cause of
chronic pancreatitis, and it has been shown to be directly toxic to the pancreatic acinar cells. It produces cytoplasmic lipid
accumulation ultimately leading to fibrosis and gland failure.57 Moreover, chronic use of alcohol can cause pancreatic secretions
to be more lithogenic, which results in stone formation and pancreatic duct obstruction. The contact of stones with the duct lumen
will ultimately lead to a cascade of events, which includes ulceration, scarring, stasis, further stone formation with eventual
atrophy, and fibrosis.86,87 In contrast to de novo stone formation as a result of alcohol consumption, repeated attacks of acute
pancreatitis from various causes including alcohol will result in peri-ductular scarring, which leads to duct obstruction with stasis
and a similar cascade of events that will lead to glandular fibrosis.88,89 Oxidized byproducts of metabolism are produced in the
liver and secreted in bile, and it is proposed that this results in oxidative stress as the bile is refluxed into the pancreatic ducts.
Oxidative stress has also been attributed to high levels of dietary lipids or alcohol.90–92 Also described is an immunologic
response that results in an attack on the ductal epithelium, an autoimmune-like reaction, resulting in scarring and fibrosis.93 A
recently proposed theory, the SAPE (sentinel acute pancreatitis event) hypothesis, combines a number of the above-described
pathogenic mechanisms leading to chronic pancreatitis. It suggests an initial event of acute pancreatitis that leads to an
inflammatory response secondary to an insult such as alcohol or oxidative stress. If this insult is removed, tissue repair occurs. If
the insult is not removed, proinflammatory cytokines activate pancreatic stellate cells resulting in chronic pancreatitis with
fibrosis and tissue destruction. This ultimately leads to reduced secretion of adequate amounts of lipase, giving rise to pancreatic
insufficiency.94,95

In CF, the mutation of the CFTR (cystic f ibrosis transmembrane conductance regulator) protein results in abnormal sodium and
chloride transport. Normally, luminal chloride is exchanged for bicarbonate, which allows for an alkaline environment within the
lumen, allowing highly concentrated proteins to remain in the soluble state. With mutant CFTR protein, the net result is
abnormally viscous secretions and an acidic lumen, resulting in ductal obstruction. Prolonged obstruction results in tissue
destruction by retained proteolytic enzymes, f ibrosis, fatty replacement, cyst formation, and eventual exocrine insufficiency.3,96

The initial effect of acinar destruction is decreased pancreatic enzyme production (Table 5). However, lipid digestion can be
maintained to reach an absorption rate of 20% to 80% due to the action of gastric lipase secreted by the fundic mucosa of the
stomach;51 indeed this lipase output is normal or higher in CP and CF patients,35,51,97 and its action take place both in the
stomach and in the duodenum, being favored by a low level of pancreatic proteases and low intraduodenal pH.51 But the
lipolysis rate reached by the gastric lipase is not always sufficient to make up for the lack of pancreatic lipase.5 As continued
glandular destruction occurs in CP and CF, the ductules are affected causing inadequate bicarbonate production and resulting in
an inability to neutralize acidic chyme.3 Along with decreased pancreatic bicarbonate secretion, gastric acid production is
increased in certain conditions associated with pancreatic insufficiency, notably advanced CP and CF.5,35,97–100 Consequently
the intraduodenal pH will be acidic (3 to 5)35,98 and will lead to enzyme inactivation and bile salt denaturation.5,71,98 The bile
salt pool is even more reduced by decreased enterohepatic circulation of bile secondary to impaired ileal mucosa absorption.101
As bile salts are required to solubilize the lipolytic products within the intestinal lumen, this process further impairs lipid
digestion and absorption.3,61

Pancreatic enzyme replacement therapy

Formulations and pharmacokinetics

The goal of supplemental enzyme therapy in EPI is to minimize nutrient malabsorption, especially of lipids, and to do this it is
important to achieve an adequate concentration of active pancreatic enzymes in the duodenum at the same time that food is
delivered.3,71 Attempting to replicate this physiologic process requires resistance to gastric inactivation and delivery of active
enzyme at the site where digestion is required, the duodenum. The composition and various formulations of pancreatin and
pancrelipase affect their use and ability to deliver appropriate amounts of active enzyme to the duodenum. Pancreatin, a crude
mixture, is derived from swine or ox pancreas, and each milligram contains no less than 2 USP (United States Pharmacopeia)
units of lipase and 25 USP units of amylase and protease activity. Pancrelipase is obtained from swine pancreas and is a more
concentrated and purified enzyme preparation. Each milligram contains no less than 24 USP units of lipase and 100 USP units of
amylase and protease activity. Because of its higher enzyme content, pancrelipase formulations are favored over pancreatin
preparations.3 A variety of delivery agents has been developed in attempts to increase resistance to destruction, and enable
delivery to sites where lipid digestion is physiologic, ie, the duodenum. The uncoated formulations are susceptible to acidic
breakdown in the stomach and are currently used largely in clinical practice to treat the pain of chronic pancreatitis and not
malabsorption.102 Enteric-coated preparations were designed to avoid inactivation in the stomach, as the enzyme is protected
from the acidic environment by the coating, and then dissolves in the duodenum when pH exceeds 5 to 5.5.3 A wide range of
polymers, natural (carboxylmethyl or succinate high amylose starch) or synthetic (methacrylate copolymers, polymer cellulose
acetate phtalate, hydroxyl propyl methyl cellulose phtalate), with different pH sensitivity, have been examined as excipients to
circumvent the gastric inactivation of enzymes and to control the timing and location of their release in enteric-coated
preparations.103,104 They are supposed to allow uniform mixing in the stomach without releasing their content and timely
delivery to the duodenum for digestion to proceed. But effective delivery and release are difficult to achieve because the pH in
the stomach can fluctuate from 6, owing to the buffering capacity of the meal, down to 2 during the fed state,98 and the duodenal
pH ranges from 4 to 6,35,105 with high individual variability. In fact, dissolution characteristics of excipients are quite different
in terms of optimum pH (5 or 5.8 for example) and time (49 to 71 minutes for the half-time of release).106–108 As a result,
enteric-coated microspheres are not bioequivalent in vitro, and probably not in vivo, depending on the pH of the duodenal
content.

Early enteric-coated formulations did not empty into the duodenum as quickly as smaller food particles, impairing their ability to
aid in digestion. Newer formulations use the enteric-coated microsphere technology that allows a smaller, yet stable delivery
system. Studies have demonstrated that the size of the particles or the microspheres affect the delivery to the duodenum, and that
particles of smaller size empty more quickly, with 1.4 mm being the optimal size.109 In theory, along with delivering adequate
amounts of lipase to the duodenum at the same time as the ingested food, microsphere technology should allow more adequate
mixture with the postprandial chyme.3 Studies of labeled capsules suggest that even with varying sizes of microspheres, the
ingested lipid may enter the duodenum in advance of the pancreatic enzyme. When, where and at how much enzyme is released
is not very well studied in humans.110 The new FDA rules in terms of pancreatic enzyme replacement therapy (PERT) have
instructed companies to set up clinical trials in order to fill this gap. The results of recent studies of delivery of pancrelipase
should be informative and could help to ameliorate coating materials (ClinicalTrials.gov NCT00676702, Pancrease MT, Johnson
& Johnson Pharmaceutical, NJ, USA; NCT00744250, Pancrecarb MS16, Digestive Care, PA, USA; NCT00559052, Viokase 16,
Axcan Pharma, Canada).

Currently, the main formulations are immediate-release, enteric-coated microspheres and minimicrospheres, enteric-coated
microtablets, and enteric-coated microspheres with a bicarbonate buffer. A comprehensive table of these medications has been
summarized in other reviews.3,76 A major focus of regulation of these products has been on the active enzyme content and
accuracy of packaging. While instability of the enzymes results in delivery medications that contain less than the packaged
amount of enzyme, the practice of ―overfilling‖ in an effort to address enzyme degradation may result in excess enzyme content,
resulting in formulations that deliver inadequate or excess amounts of enzyme. In Europe, historically these products have been
regulated, resulting in more standard enzyme content. In the United States, until recently, because of lack of stringent regulation,
studies showed marked variation in the enzyme content of the various formulations, generic products being of greatest
concern.111 The marketing of products containing pancreatic enzymes extracted from animal tissue preceded the creation of the
FDA in 1938, so that these products were historically not regulated by the FDA. In 2004, in response to concerns FDA issued a
statement requiring that all manufacturers of PERT submit New Drug Applications. Eventually, the FDA set a deadline of April
28, 2010 for approval of all pancreatic enzyme products, and at the time of submission of this article, only 3 pancrelipase
preparations have been approved for use in the United States:112 Creon (Abbott, IL, USA), EUR-1008 or Zenpep (Eurand,
Milan, Italy), and Pancreaze (Johnson & Johnson, NJ, USA). All these formulations have been demonstrated to be safe and
effective in improving lipid malabsorption and the symptoms of maldigestion. The most studied of the approved enzymes, Creon,
is an enteric-coated formulation of pancrelipase delivered in the form of minimicrospheres.113–115 Zenpep is an enteric-coated
bead preparation.116 To counteract the problem of non-uniform drug delivery raised by the FDA, this formulation of
pancrelipase enteric-coated microtablet is manufactured with label-claimed lipase content being zero-overfilled.116 Clinical
Phase III trials demonstrated an improvement in coefficient of fecal fat absorption (CFA) (88.3% vs 62.8% in placebo group) and
lipid-soluble vitamin levels.116 Pancreaze is an enteric-coated microtablet.112

In Europe availability of preparations varies by country and they are regulated nationally and not by the European Medicines
Agency. Many regulatory agencies provide information on their website and information on available enzyme preparations may
be sought through the national regulatory agency, the pharmaceuticals, or pharmacy references. In products in which the enzyme
content has been standardized, there is still a marked variability in particle size, release, and, for some, acid stability, which may
result in differences in clinical effect.106,117,118

Dosing and schedule of administration

The typical indications for starting enzyme replacement therapy are progressive weight loss and steatorrhea, defined as at least 7
to 15 g of fecal fat per day, but there are no substantial data to support these guidelines. Since steatorrhea does not typically occur
until >90% of pancreatic lipase activity is lost, 10% enzyme activity is the initial goal for therapy. Dosing is adjusted based on
the amount of lipase in the supplements, and the initial dose aims at supplying 40 to 60 IU/minute of lipase activity within the
duodenal lumen. To achieve this goal in adults, approximately 25,000 to 40,000 IU of lipase is required to digest a typical meal,
and about 5000 to 25,000 IU of lipase per snack. However, is not recommended to exceed 10,000 IU of lipase per kg of body
weight per meal.3,5,71,76 Pediatric dosing is detailed in the products‘ respective package inserts. Ultimately 50,000, 100,000 and
150,000 IU of lipase per day will decrease steatorrhea by 45%, 60%, and 70%, respectively.119 Ideally the correct amount of
lipase should be divided and administered through the course of a meal or immediately after a meal, and dose adjustments made
after several days to allow for sufficient time for the enzymes to work.5 A recent study compared three different administration
schedules using enzyme replacement before meals, during meals, or after meals. It was found that lipid digestion was better when
giving enzymes during or after meals, and patient preference did not differ.120 Currently, none of the approved enzyme
supplements are specifically designed for administration via percutaneous gastrostomy tubes. In patients who cannot swallow
large capsules, and infants, opening the capsules into a small amount of acidic food (ie, apple sauce) is an acceptable way to
administer the medication.

Monitoring therapy

Currently there are no guidelines in clinical practice for monitoring the efficacy of enzyme replacement therapy and determining
a need for dose adjustment. In research studies, a commonly used method to monitor therapy is the use of the CFA and
coefficient of nitrogen absorption. The CFA uses a 72-hour stool collection comparing the amount of lipid ingested with that
excreted.121–123 The cumbersome nature of stool studies limits their use in the outpatient setting. Commonly, determining the
efficacy of therapy is performed by clinically assessing the patient‘s weight loss or gain and diarrhea. Unfortunately, clinical
assessment correlates poorly with the patient‘s nutritional status.124,125 In a recent study, approximately two-thirds of the study
subjects, when asymptomatic, had evidence of nutritional deficiencies as measured by retinol-binding protein, ferritin, and pre-
albumin. The authors concluded that monitoring of weight loss and diarrhea is an inadequate measure of nutritional deficiencies
in EPI.126 Various breath tests have been developed, using various substrates labeled with 13C including mixed triglycerides,
triolein, and cholesteryl octanoate.127–129 As an example, the 13C-labeled mixed triglyceride breath test uses a labeled substrate
with two molecules of stearic acid and octanoic acid. Lipolysis is associated with measured release of labeled carbon dioxide.130
This test was shown to be accurate in estimating pancreatic exocrine function and has been shown to correlate with nutritional
markers when estimating response to enzyme supplementation.131,132 Because stool collection is often time consuming and
difficult, and breath tests are not readily available in all locations or fully validated as a clinical tool, following patients clinically
is the common approach in determining the efficacy of PERT. As the degree of symptoms and symptom improvement do not
always correlate with the patient‘s nutritional status, in the future we would hope for more clinically relevant and widely
available tests to monitor therapy, most likely in the form of a breath test or a spot stool test.124–126

Efficacy

Although the efficacy of enzyme replacement therapy is presumed, the data are not as robust as one might hope. Although
numerous studies have evaluated the response to treatment for outcomes such as steatorrhea and fecal fat, surprisingly few have
studied improvement in nutritional status, even in weight gain.2,113–116,122,133 Enzyme supplements have been found to
improve lipid malabsorption compared with placebo in numerous trials, for both adults and children younger than 7 years
old.2,113–116,122,133 They have also been shown to improve symptoms related to pancreatic insufficiency such as abdominal
pain, flatulence, stool consistency, and improve overall global impression of disease symptoms.113 A systematic review of the
randomized trials of PERT identified only two studies that evaluated weight as an outcome, and the difference was not
significant.134 It has been reported that in patients who were considered to be on acceptable replacement therapy, with reduction
in steatorrhea, markers of significant malnutrition still persisted as measured by retinol-binding protein, transferring, and
prealbumin.126 In a prospective, non-placebo controlled study, this group has also reported that increasing enzyme therapy to
normalize 13C-mixed triglyceride breath test did significantly improve key markers of nutritional status at 1 year.132 As such,
although it is presumed, the reduction in stool fat achieved by PERT has not been proven by rigorous research to be correlated
with a complete correction of nutritional deficiency in patients with pancreatic insufficiency, preventing our overall assessment
of the efficacy of this therapy. In the future, demonstration of long-term outcomes would also be of interest.

Safety and side effects

In general, PERT is regarded as safe with few side effects, and adverse events are comparable to those with placebo.2
Supplemental enzymes act within the lumen of the intestine, and this is considered an intraluminal and not a systemic therapy.
The most commonly reported side effects for recently approved enzymes are headache (6%), dizziness (6%), abdominal pain
(9%), and flatulence (www.micromedex.com). Historically, hyperuricemia, and hyperuricosuria, which leads to dysuria and uric
acid crystaluria, have been reported in cystic fibrosis patients with older formulations.135 Folic acid deficiency has been
associated with use of pancreatin extracts which may form insoluble complexes with folate.76 Irritation of the oral mucosa may
be avoided by not chewing the medications, or mixing them in foods with a pH > 4.5 (package inserts). A theoretical risk exists
of xenotic viral infections, although such cases have not been reported. As more concern is focused on the effect of pthalates,
which are commonly present in the polymer coating, the impact of this component will likely be evaluated further.136 The most
concerning adverse effect associated with enzyme replacement is fibrosing colonopathy, which has been described in cystic
fibrosis patients receiving <24,000 IU of lipase/kg daily.137,138 It results in submucosal collagen deposition with fibrosis and
varying degrees of stricturing. Some studies suggest that the acid-resistant coating of enzyme preparations may be responsible for
the fibrosing colonopathy, as it has also been demonstrated with other medications that use the same methacrylic copolymer
coating.76,139–143 In addition, as these cases largely occurred with high-dose enzyme therapy (>50,000 IU/kg daily), limits are
suggested for maximum dosage and delivery. Caution should be used when doses exceed 2500 IU/kg per meal. Most
formulations are considered pregnancy class C, as there are insufficient data to evaluate their safety, and no data are available on
their secretion in breast milk.

Treatment failure

Despite optimal dosing of enzymes and clinical assessment, treatment failures are common. A systematic approach is beneficial
in determining the reason for treatment failure (Figure 1). The first step is to assess compliance, diet, and timing of
administration. Studies have demonstrated that efficacy is maximum if medications are taken during and after a meal, and such a
schedule may need to be detailed with the patient.5,120 Although wide variation has been noted between products,106,107,111 at
this point there is inadequate information to recommend changing formulation if the medication is not working, although this is
not an unreasonable practice, given the fact that there are documented differences in delivery and release among the marketed
products.117,118 Certainly, in areas in which generic medications are available, if the medication loses its clinical effect in an
individual, it should be determined if the medication has been changed to a generic form, and changed to brand name medication
if appropriate. If compliance is in question, a fecal chymotrypsin test can be performed to confirm compliance. If these
possibilities are eliminated as primary causes of loss of clinical effect, and secondary causes of diarrhea are less likely by history
and exam, the first option is to increase the amount of lipase given to see if response improves. If this is not successful, dietary
habits may need modification, in particular, a reduction in lipid intake to 50 to 75 g per day.71 Other treatment modifications
may include reduction in fiber intake, avoidance of alcohol, and minimizing calcium- and magnesium-containing antacids, as
these can all increase steatorrhea. The next step is usually to administer acid-suppressing medications, either histamine-2 receptor
blockers or proton pump inhibitors. Studies have shown improved lipid digestion and absorption with administration of acid-
suppressing medications to nonenteric-coated formulations.144–146 Furthermore, it has been shown that acid suppression in
addition to enteric-coated formulations will improve steatorrhea, and may enable the use of lower amounts of lipase.147 Finally,
if all the above steps fail, diagnostic evaluation for other etiologies for continued steatorrhea is warranted, including small
intestinal bacterial overgrowth, giardiasis, blind loop syndrome, and other absorptive problems.37,71,76

Future developments for an optimal therapy

The challenges of current obstacles to effective therapy

Optimal lipid digestion and absorption is not always reached in EPI patients, which is assumed to be due largely to problems with
delivery of active lipases at the appropriate intestinal site (duodenum) and time of delivery. Also, the amount and the type of
enzymes administered fails to mimic normal human pancreatic secretion that is specific to age and to each individual. Treatment
requires intake of multiple capsules and is expensive. Problems of allergy to porcine proteins and religious or other cultural
concerns with the use of pork products also have to be taken into account. To address these issues, ongoing research is focusing
on identifying new enzyme sources, more efficacious lipases, and strategies to enable improved delivery throughout the digestive
process. Standardized, rapid, in vitro test systems to measure the efficacy of such lipases in near physiologic conditions need to
be set up for screening and to help create more accurate PERT product labeling.

Supplementation of duodenal bicarbonate

Acidic degradation of exogenous pancreatic lipase and the discrepancy between an optimal pH for enzyme action and the actual
intra-duodenal pH in EPI patients are major factors that prevent complete correction of steatorrhea.71 One answer is to increase
the local duodenal pH. The use of sodium bicarbonate (1.34 g per test meal) with enteric-coated tablets of pancreatic enzymes
combined with desiccated ox bile (50 mg per test meal) considerably improved lipid digestion as measured by breath-test in
patients with chronic pancreatitis, without concurrent acid-suppressive therapy.148 More recently, the effect of administering
enteric-coated buffered pancrelipase microspheres (Pancrecarb MS-8, Digestive Care Inc, PA, USA) containing 2.5 mEq149 or
1.5 mEq150 of bicarbonate per capsule was tested on CFA in CF patients. In both studies, the number of patients, lipid
consumption, stated lipases units/kg per day (about 4400 USP) were similar, and patients were their own controls. A significant
increase in CFA (9%) was observed only in the study providing the higher amount of sodium bicarbonate (about 6.9 g daily
versus 3.1 g daily).149 The results of these studies are difficult to interpret, as individual responses to the buffered PERT varied
widely, probably because CF patients can secrete either normal or high levels of gastric acid postprandially.98,151 As a result,
there would be marked individual variability in duodenal pH as a response to the amount of bicarbonate provided.

Alternative sources of lipases

In order to avoid the short half-life of lipolytic enzymes of pancreatic origin for replacement therapy, a variety of lipases have
been tested from sources as diverse as animal gastric lipase and microbial or plant lipases.

Supplementation with gastric lipase has been evaluated because of the natural acid-resistant properties and broad pH of action (3
to 6) of the enzyme.51,152 A dog recombinant lipase, rGL, was produced to test this concept153 and was developed by the
French company Meristem Therapeutics SA, Clermont-Ferrand (Merispase), that went out of business in September 2008. This
approach is problematic for several reasons: gastric lipase specific activity is about 10 times lower than that of pancreatic lipase
(measured on tributyrin);51 it is highly sensitive to trypsin proteolysis;154 and endogenous secretion of gastric lipase can be
increased in patients with pancreatic insufficiency28 because of possible nutritional adaptation.98,155 However, gastric lipase
supplements may still be a viable option. Indeed, during gastric lipolysis, endogenous human gastric lipase is rapidly trapped
within fatty acid-rich particles generated at the surface of the lipid droplet and is no longer able to access its substrate.156 The
addition of an extra dose of gastric lipase through supplementation will allow lipolysis to continue.156 Also, in vivo specific
activity of gastric lipase can be close to that of pancreatic lipase especially on a solid food matrix.38 Two clinical trials conducted
in CF patients showed that rGL is well tolerated and efficient when administered at the dose of 600 mg alone, or when associated
with pancreatic extract (PE) (≥300,000 UPS total per day). This combination led to a significantly increased CFA compared with
PE alone (84% vs 71%) in 7 of 11 patients.157 Another study showed that 250 mg rGL combined with a low dose of pancreatic
extract led to at least equal CFA compared with a high dose of PE.158 Furthermore, there was a greater benefit in CF patients
with low CFA, which also improved quality of life.158

Microbial lipases of fungal or bacterial origin are of potential interest because of their acid and protease-stable properties and
their activity at pH 3 to 10. Rhizopus arrhizus,159 Candida cylindacea, Aspergillus niger,160,161 and Yarrowia
lipolytica162,163 are some examples of the most tested fungi. The Aspergillus and Yarrowia species have better survival in the
duodenal environment as shown in vitro and in rats, while the others appeared very sensitive to trypsin and to the detergent action
of bile salts. Lipases derived from bacteria are more promising as they are highly resistant to both acid and alkaline inactivation,
stable in the presence of both proteolytic enzymes and bile salts, and active without the need for bile salts and colipase.164 A
novel, experimental type of enzyme supplement containing bacterial lipase, fungal protease, and amylase (TheraCLEC-Total or
ALTU-135, Altus Pharmaceuticals, MA, USA) has demonstrated good tolerance and efficacy (20% increase in CFA).164 A
Phase II clinical trial showed that a moderate dose (25,000 USP of lipase per meal) resulted in a 35% to 40% increase in the CFA
of cystic fibrosis patients with 0% to 40% CFA at baseline, and that a high dose (100,000 USP lipase per meal) was necessary for
a 10% increase in the CFA of patients with 41% to 80% baseline CFA, after 1 month‘s treatment.165 A 1-year, multi-center,
Phase III clinical trial was completed in 2009 (ClinicalTrials.gov NCT00500084) and results are pending.166 Thus, Liprotamase
(formerly known as ALTU-135 and Trizytek), for which a pediatric formulation is in progress, is the first porcine-free PERT
developed since the end of 2008 (Alnara Pharmaceuticals, MA, USA, acquired by Eli Lilly, IN, USA).167 A better knowledge of
the microbial lipases structure and modes of action will probably help to select and design much more active enzymes in the near
future.168,169

Plant acid-stable lipase, as in oats,170 and plant latex lipase extracts from euphorbia characias, fruit of babaco, or carica
papaya171,172 are potential sources of lipases. At this point, kinetics have been studied only in vitro and scientific data are
needed on their digestive function in physiological conditions.

Recombinant human lipases

Recombinant human lipases would be expected to offer superior safety by decreasing the risk of allergic reactions. Progress in
protein engineering173 and a detailed knowledge of human lipases174 will enable large-scale production and the ability to apply
directed mutagenesis if necessary for improving lipase stability and activity in acidic conditions. Of note, the use of recombinant
human lipases may be limited by the fact that changes in glycosylation (rates and type) and other post-translational modifications
in proteins produced in the non-eukaryotic cell system used for large-scale production may interfere with enzymatic
activity.175,176

A promising candidate for the treatment of lipid malabsorption is a recombinant human bile salt-stimulated lipase (rBSSL). This
enzyme is naturally acid resistant and able to hydrolyze triglycerides and phospholipids.59 Two preparations dedicated to cystic
fibrosis patients and preterm infants, Exinalda and Kiobrina, respectively, are currently under development (Biovitrum AB,
Stockholm, Sweden). A Phase I clinical trial was conducted in 9 CF patients with EPI, measuring lipid uptake through breath-
test.177 The addition of rBSSL (0.2 or 1 g) to standard pancrelipase (Creon) enabled a dose reduction of pancrelipase to 25% of
normal dose.177 Plasma chylomicron level was significantly higher with the addition of rBSSL (34% to 48%), a clear secretion
peak being reached at 3 hours after the meal,177 which is similar to the pattern found in normal subjects,30 while no real peak
was observed with pancrelipase dosing alone. This can be explained by the ability of BSSL to generate lysophospholipids
necessary for an efficient lipid absorption rate by the small intestine,61 and to participate in chylomicron assembly and secretion
through its ceramidase activity.14 Another study was conducted through 2009 with Exinalda in 18 CF patients with EPI in
Poland and the Netherlands, but the results have not yet been published (ClinicalTrials. gov NCT00743483). Two Phase II
clinical trials have been conducted in Italy and France with Kiobrina administered at a dose physiologically found in human milk
(0.15 g/L) for 1 week to premature infants in formula (ClinicalTrials.gov NCT00658905) or in pasteurized breast milk
(ClinicalTrials.gov NCT00659243), but results are not yet available.

Directional mutagenesis and use of electrostatic computations has also allowed generation of a human pancreatic lipase with
modified pH of action (pH 4–5).178 Pancreatic lipase is irreversibly inactivated by gastric acid at a pH of 4.0 and below and its
activity is very low at pH 5.0.10 Several variants of the recombinant human pancreatic lipase were generated by error-prone PCR
and screened for stability and activity at a pH of 5 in vitro.179 Although these enzymes were more acid stable, their activity on
physiologic substrates was not enhanced compared to native human pancreatic lipase.
Delivery system strategies

Bacterial engineering and gene transfer techniques could revolutionize the delivery of pancreatic enzymes by producing the
enzymes within the host. Strains of bacteria such as Lactococcus lactis, genetically modified to highly express bacterial lipases,
have been derived.180 Colonization of pigs with experimentally induced pancreatic insufficiency with lipase-producing L. lactis
demonstrated increased CFA under a high-fat diet.181 The treatment occurs as the bacteria release their cellular content in
response to contact with proteolytic secretions and bile acids.181 A gene therapy approach could be envisioned as an alternative
therapeutic strategy to improve lipid digestion and absorption in EPI patients by mediating enzyme production by transduced
cells within the treated patient. Indeed, the human pancreatic lipase gene has been successfully expressed in the biliary tract in
rats using recombinant adenovirus.182

Strategies through substrate physicochemical properties and lipase activators

As an alternative, creating functional dietary lipids that are more effectively digested is another frontier of treatment for
pancreatic insufficiency. Triglyceride digestion is more efficient when the substrate is emulsified, ie, dispersed, in aqueous
medium as lipid droplets which consist in a core of triglycerides stabilized by a layer of phospholipids or other emulsifiers. The
process of emulsification creates a lipid–water interface allowing optimal action of lipases.183 The physicochemical properties of
such an interface can modulate the rate of lipolysis.183,184 Thus, structuring food emulsions is a new concept that should
improve lipid digestion and absorption in EPI patients by selecting the best lipid physicochemical properties for optimal action of
lipases.28,30,185,186

Lipid droplet size is one of the key physicochemical parameters of triglyceride digestion by gastric and pancreatic lipases, as it
governs the lipid–water interface area.29,30,155 Droplet size is inversely related to the lipid interface area, and, theoretically,
small-sized droplets should be more efficiently digested in the digestive tract offering a larger interface area that will allow the
binding of more lipase molecules at the interface. Indeed, it was shown in healthy humans that the triglycerides from small-sized
droplets (0.7 μm) are more efficiently digested in the stomach and in the duodenum than from larger droplets.30 Even though this
has a potential for health, it has not been tested yet in EPI patients.

Another physicochemical key factor involved in lipid digestion is the ultrastructure, ie, droplet surface layer composition
(phospholipid classes, phospholipid fatty acid profile, adsorbed proteins).184 Lipases bind to such a surface layer to access to
triglycerides contained in the core of the droplet. The composition of the droplet surface layer plays a key role in vivo as it was
shown that native human milk droplets of about 4 μm (three phospholipid layers) were more efficiently lipolyzed in the stomach
of premature babies than small-sized droplets (0.5 μm) from a formula (single layer).56 It was shown in vitro that specific classes
of phospholipids will prevent pancreatic lipase activity,187 or enhance dramatically gastric lipase, pancreatic lipase, and BSSL
activity in conditions that mimic physiology.188,189 Also, the dietary protein interaction within the droplet surface can improve
or diminish the triglycerides lipolysis rates.190

A third physicochemical property of lipids that is of particular importance in patients suffering from digestive and absorptive
disorders is the triglyceride structure, ie, the nature of fatty acid esterified at positions sn-1, sn-2, and sn-3 of the glycerol
backbone.191–194 Indeed, this structure influences digestion, as the lipolysis rate depends on the type of fatty acid present at the
sn-1 and sn-3 positions,195 and the lipid droplet size can differ depending on the triglyceride structure.196 Triglyceride structure
also affects i) the absorption step, as the fatty acid is better absorbed when it is present as a 2-monoglyceride;193,197,198 ii) the
enterocyte re-synthesis step and the secretion of chylomicrons by the enterocyte, as the fatty acid of the sn-2 position is retained
in chylomicron lipid particles; and iii) the lipid metabolism.198,199 So, the structure of triglycerides is particularly important to
improve absorption of essential and very-long chain fatty acids.193,200 In contrast, absorption of long-chain saturated fatty acids
can be dramatically decreased when present at the sn-1 and sn-2 positions of the triglyceride molecule and in the presence of high
concentration of calcium or magnesium, because they form insoluble soaps.197 Except for Betapol (Lipid Nutrition, Hogeweg,
the Netherlands) used in several milk substitutes because it is a source of structured triglycerides with long-chain saturated fatty
acids in sn-2 position, as in human milk,192,193 other kinds of structured triglycerides are not often used, probably because of
their cost.193

Functional foods are a new area of research for clinical nutrition. For EPI patients, specific, more digestible or absorbable lipid
sources could be designed. The addition of specific phospholipids able to enhance lipase activity in enzyme supplements or in
formula would both increase lipase activity and, in parallel, enhance lipid nutrient absorption.

Conclusion:
Exocrine pancreatic insufficiency results from a wide range of medical and surgical conditions. PERT is the standard treatment
for the resultant malabsorption. Therapy is in general well tolerated and efficacy is satisfactory. Although progress has been made
in standardizing therapy and improving enzyme formulations, there is still room to improve in terms of fully resolving the
symptoms and malnutrition related to EPI, along with convenient and accurate means for monitoring therapy. In the clinical
setting, a basic understanding of the physiology of enzyme delivery assists in choosing, monitoring, and adjusting therapy.
Currently the most common monitoring strategy is clinical response, as stool fat and breath testing are cumbersome and less
clinically available. Dose adjustments can be made according to the amount of steatorrhea and the patient‘s weight loss or gain.
The common problem of incomplete response to therapy might also indicate that the mechanism of malabsorption in pancreatic
insufficiency is more complex than simply a lack of pancreatic enzymes and electrolyte secretions, and further study in this area
is warranted. In the future, with the advent of new technology, we look forward to delivering even better tolerated replacement
therapy, which replicates more accurately the function of the native pancreas or delivers nutrition more effectively, and more
convenient or available means of monitoring therapy.
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this practice in his book Traité de Microbiologie, vol. 2 (Paris, France: Masson and Co., 1899). See Chapter 1, especially page 9.

Willstätter, R. (1927). Problems and Methods in Enzyme Research. Cornell University Press, Ithaca. quoted in Blow, David
(2000).

"So do we understand how enzymes work?" (pdf). Structure 8 (4): R77–R81.doi:10.1016/S0969-2126(00)00125-

8. PMID 10801479.el prize for Chemistry laureates at http://nobelprize.org.