After reviewing over 30 studies, Bucci stated that there were "more frequent side effects from placebos than from proteases."1 The most common negative side effects of proteolytic enzymes are gastrointestinal. A few people will complain of upset stomach or nausea when taking enzyme preparations. If this occurs: (1) ask the patient if they have a sensitivity to the source of the enzyme, for example, beef, pork, papaya, and pineapple; and (2) change formulas/brands.1
Weights and Measures
Weights and measures have been one of the biggest problems with the use of proteolytic enzymes. There are no uniform measurements of activity; thus, it is not possible to compare the strengths of different preparations or different types of enzymes. Common measurements used include United States Pharmacopeia (USP); Armour units, Rohrer units; milk clotting units (MCU); gelatin-dissolving units (GDU); and national formulary units (NF). There is no conversion equation to determine if 100 mg of brand A that has 500 MCU of potency is stronger or weaker that 50 mg of brand B that guarantees 1,000 USP of activity. To make matters worse, many brands are sold by their weight, which has nothing to do with how active the product is.
- Start ingesting enzymes as soon as possible after the injury.
- Take enzymes on an empty stomach. Any time food is present in the stomach or small intestine, serum uptake is reduced.
- Enzymes must be taken throughout the day to maintain peak serum levels; therefore, they should be taken a minimum of three times per day. Most manufacturers recommend dosing five or six times for maximum effectiveness.
- Enterically coated preparations are much preferred, although not mandatory with bromelain.
- Multiple types of enzymes increase the chances of disrupting the inflammatory cascade by increasing the range of peptide bonds that can be attacked.
- Enzymes should be used for one week or until signs and symptoms improve.
- Tissue saturation is imperative for enzymes to be effective. Tissue saturation is achieved with a patient's complaints of loose stools.
- When stools loosen, reduce the dose slightly and maintain at that level.
- Because of the problems with weights and measures, it is strongly advised that along with whatever product you use, you also contact the company to obtain a realistic amount required to reduce inflammation. Most companies label their products in a very conservative manner, and if patients simply follow the label, they will not be pleased with their investment.
- Unlike many nutritional supplements, proteolytic enzymes have a relatively short shelf life (one year). Therefore, if you do carry proteolytic enzymes in your office, purchase them in amounts that will turn over rapidly. This will increase the chances that what you recommend is fresh and active.
- When you find a formula that works for you and your patients, stay with it.
Until manufacturers can come up with uniform standards for clinicians to compare and recommend these products in a rational manner, utilization of enzymes will be continue to be less than it should be. I know of no other vitamin, mineral, herb or nutraceutical substance which the experts recommend to "take a bunch of pills four or five times a day."
If you can get by the frustrating weight and measure issue, you will find that proteolytic enzymes can be a useful tool in your practice.
1. Bucci L. Nutrition Applied to Injury Rehabilitation and Sports Medicine. Boca Raton, FL: CRC Press, 1995.
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