Many diseases of modern people are caused by enzyme deficiency. Previously, this problem was associated with age-related changes, but now more and more often a lack of enzymes in the body occurs in young people. What are they, how do they affect health and how to make up for the deficiency of these important substances? Let's figure it out.

What are digestive enzymes for?

All vital processes are provided by thousands of chemical reactions. They occur in the body in mild conditions, without exposure to high pressure and temperature. Substances that are oxidized in human cells burn quickly and efficiently, providing the body with building materials and energy.

Rapid digestion of food in the cells of the body occurs under the influence of enzymes, or enzymes. These are biological catalysts, which, according to their functions, are divided into 3 large groups:

1. Amylase. This is the collective name for a group of enzymes that digest carbohydrates. Each type of carbohydrate has its own type of amylase. Such enzymes are secreted along with gastric juice and saliva.
2. Lipase is a group of digestive enzymes that break down food into fats. They are secreted in the stomach and pancreas.
3. Protease is a group of enzymes that digest proteins. These digestive enzymes are synthesized with gastric and pancreatic juice, like lipase.

Swallowed food enters the stomach. There it is broken down by gastric juice, which contains hydrochloric acid and a number of digestive enzymes, including lipase, pepsin, and renin. Due to the lack of enzymes, a large amount of food is often not completely digested. In this form, food enters the alkaline environment of the duodenum 12. Here, pancreatic enzymes trypsin, elastase, amylase, lipase, carboxypeptidase and chymotrypsin, as well as bile, act on food.

Most foodstuffs after processing with the participation of digestive enzymes are absorbed in the small intestine. A smaller part enters the large intestine. Water is absorbed there, so the semi-liquid contents of the intestine gradually thicken. In this process, again, an important role is assigned to enzymes, as well as dietary fiber.

In the process of digestion, carbohydrates are broken down into monosaccharides (mainly glucose), proteins into amino acids, and fats into fatty acids. Then the transformation products are absorbed through the intestinal walls into the blood and delivered to the tissues of the body, where they participate in intracellular metabolism.

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Why is an enzyme deficiency formed and why is it dangerous?

Modern man does not get enough enzymes from food. The reason lies in the heat treatment, since living enzymes are finally destroyed already at a temperature of +118 degrees. Do not contain enzymes and semi-finished products. Sterilization, pasteurization, repeated cycles of freezing and thawing, microwave cooking - all these processes inactivate digestive enzymes and disrupt their structure.

Foods devoid of live enzymes put a lot of stress on the body. To digest such food, he has to activate the production of additional enzymes, and at this time the synthesis of other important substances is inhibited.

Violation of digestion is fraught with the occurrence of diseases of the gastrointestinal tract, pancreas, liver, gallbladder. Signs of a digestive enzyme deficiency include:

• heartburn;
• flatulence;
• belching;
• headache;
• diarrhea;
• constipation;
• stomach colic;
• gastrointestinal infections.

These symptoms are experienced by a huge number of people, taking them for a common ailment. In fact, such signs signal that the body is not able to actively process food. The digestive organs work for wear and tear, their normal work is disrupted. On this soil, diseases of the endocrine system, the musculoskeletal system develop, and immunity decreases.

The problem of obesity, which in the 21st century is becoming an epidemic, is associated with the peculiarities of modern nutrition. People now eat complex meals that are high in fat and sugar. There are practically no fibers and digestive enzymes in them.

Foods that contain excess fats and "fast" carbohydrates are harmful. It leads to various diseases, reduces life expectancy. Scientists have found that after heat treatment, no enzymes remain in fats. At the same time, the body needs fats, as it is a powerful source of energy. Even without them, it is impossible to fully assimilate fat-soluble vitamins.

US scientists examined a group of people weighing in the region of 105-110 kg. All had a lack of lipases - enzymes that ensure the breakdown of fats. With a deficiency of these enzymes, fats are simply deposited on the hips, waist, liver, and other organs and parts of the body.

The situation is similar with carbohydrates. Carbohydrates contained in fruits and other natural products that are not subjected to heat treatment retain enzymes, B vitamins, and chromium. The problem is that now people eat a lot of refined sugar, and it has no digestive enzymes, no B vitamins, no chromium. To process this product, the body is forced to synthesize a large number of additional enzymes.

Due to the deficiency of proteases, allergic reactions and candidiasis develop. We are talking about digestive enzymes that break down and remove foreign substances of a protein nature from the body. Among them are viruses, fungi, bacteria.

Enzyme Sources

As long as the body has enzyme activity factors, it produces new enzymes. Their "additional" source is food. Food containing live enzymes greatly facilitates digestion. Thermally processed food, which is devoid of enzymes and forces the body to produce them on its own, reduces the already limited enzyme potential. It is given to a person at birth and is designed for a lifetime.

Food

Rich sources of "extra" enzymes are fermented milk products, especially natural yoghurts and kefir. Many digestive enzymes are contained in sauerkraut, fermented kvass and apple cider vinegar, exotic miso. They are rich in fruits and vegetables, but only in raw form, since heat treatment destroys enzymes. Particularly rich in these substances are garlic, horseradish, avocado, mango, papaya, grain and seed shoots, and soy sauce.

Enzymatic preparations

To compensate for the deficiency of digestive enzymes, medicines can be used:

1. Pancreatin-containing. These include Mezim, Creon, Pancreatin. Such drugs are optimal for maintaining the functions of the pancreas.
2. Means with bile acids and other auxiliary components - Festal, Panzinorm. They stimulate the intestines and pancreas.
3. Preparations for the normalization of the work of the endocrine glands and the establishment of their own synthesis of enzymes - Oraza, Somilase.

Usually take 1-2 tablets during or after a meal. Like other medicines, enzyme preparations have contraindications and side effects. Therefore, it is safer to fill the deficiency of enzymes with the help of products, although they are less effective.

Before taking enzyme preparations, it is recommended to consult a doctor. Diagnostics is needed to identify which enzymes in the body are not enough. Digestive enzymes provide a short-term effect, and in order to restore metabolism, it is important to eliminate the root cause - cure the disease, adjust the diet or change your lifestyle.

What enzymes do dieters need?

When dieting for weight loss, the production of digestive enzymes is reduced. The content of enzymes in gastric and pancreatic juices and saliva becomes scarce, so a person needs to make up for their deficiency.

You can use digestive enzymes of animal and vegetable origin. Animal enzymes can be addictive, so it is preferable to take plant-based ones. Among them are bromelain, which is extracted from pineapples, and papain, contained in papaya fruits. These digestive enzymes remain active at temperatures much higher than inside the human body.

Fresh fruits and vegetables contain enzymes, but in insufficient amounts. Initially, they contain enzymes responsible for maturation. As fruits and vegetables ripen, some of the enzymes return to the seeds and stems. Therefore, only the juice of an unripe fruit is taken to isolate papain. In ripe papaya, there is a slight content of enzymes.

One of the most common causes of weight gain in our time is insufficient production of pepsin in the digestive tract. In this case, it is useful to take bromelain. It is a powerful biological catalyst for carbohydrate and protein metabolism. It indirectly contributes to the accelerated breakdown of fats and their removal from the body. This plant enzyme also prevents the formation of subcutaneous fat deposits. On average, 1 g of high activity bromelain burns up to 900 g of fat.

Bromeilan works in different ways, it depends on the meal. When consumed with food, it serves as a digestive enzyme, helps break down and absorb proteins, activates other enzymes, and generally normalizes digestion. Bromelain also improves the functional activity of the intestine, stimulating the excretion of metabolic products and toxins, maintaining the microflora of the large intestine. As a result, metabolism is normalized. When taking bromelain on an empty stomach, it has an anti-inflammatory effect, relieves pain and swelling, therefore it is used for joint diseases. It also reduces blood clotting.

Papain is a proteolytic enzyme that breaks down proteins. It is found in all parts of papaya except for the roots. This enzyme contains lysozyme, which destroys the toxins of various pathogens of infectious diseases, including staphylococci and streptococci. Papain also prevents the formation of blood clots in the vessels, accelerates the healing of wounds and trophic ulcers, bedsores. It stimulates their cleansing from necrotic masses. For those who lose weight, it is important that papain is often included in preparations for weight normalization. It improves digestion and breaks down proteins to a state in which they are quickly and easily absorbed.

The process of digestion is complex and multi-stage. When food enters the oral cavity, a whole chain of processes is launched aimed at its mechanical grinding and chemical breakdown into substances that the body is able to assimilate. For the chemical processing of food, the digestive tract secretes digestive juices containing enzymes. If the secretion of enzymes is insufficient, a person develops various dyspeptic disorders, he feels heaviness in the abdomen, nausea, he has belching, problems with stool, flatulence. Enzyme deficiency can be eliminated by tablets for digestion. About what drugs are most often prescribed by doctors and what effect they have, read the article.

Why take enzymes?

Enzyme deficiency is usually an acquired condition. It develops when the enzymes produced by the body are not enough for efficient digestion. This condition is observed when eating too heavy food, overeating, with a decrease in the activity of enzymes in the body.

When digestion is inefficient, proteins, fats, and carbohydrates are not fully digested, leading to stomach discomfort and problems with bowel movements. By the way, with enzyme deficiency, diarrhea is more common.

If the lack of enzymes is observed for a long time, other symptoms related to non-specific appear. Due to the lack of nutrients, a person loses weight. Deficiency of vitamins and microelements leads to pallor of the skin, its peeling, hair loss, brittle nails, increased irritability, and general weakness. With a tendency to diarrhea in a person, the water balance can be disturbed. All this leads to a general deterioration in well-being, a decrease in mental activity, and neuroses.

The most effective enzyme preparations

The main goal of enzyme deficiency therapy is to improve the digestive process. To do this, the doctor may prescribe the patient enzymes for digestion in tablets. We list the most effective of them below.

Festal

The main component is pancreatin, it compensates for the insufficient work of the pancreas. The amylase, protease and lipase included in it increase the efficiency of digestion of proteins, fats and carbohydrates and improve their absorption. The drug also contains bile components, which facilitate the breakdown of fats, and hemicellulase, which improves the process of fiber breakdown. Thanks to this composition, Festal tablets have proven to be effective, quickly improving digestion.

It is recommended to take the drug during meals or immediately after the meal. Dragee washed down with plenty of water. The daily dose can be 3-6 tablets, this amount is distributed between 3 meals. The course of therapy can last from several days to months. Duration of admission depends on the improvement of the patient's well-being.

Festal has an affordable price. A package with 40 dragees will cost about 250 rubles.

Unlike Festal, Mezim contains only pancreatin as an active substance. Amylase, lipase and protease in its composition improve the digestion and absorption of carbohydrates, fats and proteins from food. These are effective tablets that help digestion. They can be prescribed both for disorders of the gastrointestinal tract caused by chronic diseases of the pancreas, stomach, liver, gallbladder, and in the absence of gastrointestinal diseases, with dyspeptic symptoms associated with overeating and malnutrition.

Important! A contraindication to taking the drug is acute pancreatitis and exacerbation of the chronic form of the disease.

The cost of Mezim is about 80 rubles for a pack of 20 tablets.

Micrasim

The drug is produced in the form of gelatin capsules containing pancreatin microgranules, the dissolution of which starts in the intestine. The enteric coating does not allow gastric juice to reduce the effectiveness of the drug. After the food enters the intestines from the stomach, the process of exposure to it of pancreatic enzymes, which are contained in Micrasim, begins. Due to the fact that the components of the drug act exactly where they are needed (in the intestine), the effectiveness of therapy will be higher.

The advantage of the drug is the possibility of therapy in newborns and people who have difficulty swallowing tablets. The cost of Micrasim is about 180 rubles for 20 capsules.

Creon is an effective medicine, available in the form of capsules. Its active substance is pancreatin. When taking capsules, a more complete absorption of proteins, carbohydrates and fats from food is achieved, and the process of secreting the body's own digestive enzymes in the body is also improved. Like the above Micrasim, Creon is an enteric drug, that is, the release of the active ingredient from the capsule occurs in the intestine. Due to this, the action of Creon is much more pronounced than the effect of taking enzyme preparations in the form of tablets.

Important! The capsule should be swallowed whole, without opening. Only in this case, the microgranules will reach the intestines unchanged and will have the desired effect.

Creon is available in several varieties with different content of the active substance. The price of the drug depends on this, for example, 20 capsules of Creon 10,000 costs about 250 rubles, and 20 capsules of Creon 25,000 costs 550 rubles. The dosage is set by the doctor individually for each patient.

Ermital is similar in action, composition and form of release to Creon, but it is less popular and less often prescribed by doctors. Ermital is produced by the German pharmaceutical company Nordmark. Ermital, like Creon, is produced in the form of enteric capsules.

The drug contains pancreatin, which compensates for the lack of pancreatic enzymes, improves the digestion process, and eliminates various symptoms of dyspepsia. The cost of Ermital is almost 2 times lower than the price of Creon, in terms of action and dosage, the drugs are analogues.

The most affordable pills to speed up digestion are Pancreatin. Tablets under this trade name are produced by several Russian pharmaceutical companies at once: Biosintez, Pharmstandardleksredstvo, Pharmproekt, Aveksima, Valenta, ABBA Rus. The cost of the drug starts from 20 rubles for the minimum number of tablets.

Due to the fact that the tablets have an enteric coating, it is impossible to bite them when taken. They are swallowed whole with water. It is recommended to take the medicine with meals or right before meals. The dosage is selected by the doctor depending on the degree of enzyme deficiency and the age of the patient.

Enzistal is a drug with a combined composition. According to the components included in it, Enzistal is an analogue of Festal. In addition to pancreatin, it contains hemicellulase and bile extract. These components provide improved digestion, free the intestines from gases and prevent their formation due to the breakdown of fiber.

As a rule, adults are prescribed 3 to 6 tablets per day. This amount is divided into 3 doses. Like other enzyme preparations, Enzistal should be taken with meals or before a meal.

The cost of Enzistal starts from 130 rubles per pack of 20 tablets. The drug is produced by the Indian company Torrent.

Somilase

Somilase is produced in tablets, the shell of which ensures the release of active substances in the intestine. Somilase contains the enzymes amylase and lipase as active ingredients. With their participation, the breakdown of carbohydrates and fats occurs and their more efficient absorption in the intestine is achieved. The drug is prescribed for mild enzyme deficiency. You need to take the tablets with meals.

Despite the fact that enzyme products are classified as over-the-counter, it is not safe to take them without a doctor's prescription, especially for a long time. They, although rare, have side effects in the form of allergies and indigestion. With prolonged use, enzyme agents can lead to the “lazy pancreas” syndrome, which is characterized by a decrease in the activity of the organ due to addiction to drugs.

Digestion is a single, holistic process due to the close relationship between the activities of the various parts of the digestive tract. Violation of the functions of one of the sections of the gastrointestinal tract, as a rule, leads to a breakdown in the function of other organs. In different parts of the digestive tract, different processes of assimilation of nutrients take place. In the stomach - protein breakdown, secretion of intrinsic factor, oxidation of iron ions; in newborns - the breakdown of fats (the formation of diglycerides under the action of gastric lipase). In the duodenum - the intake of bile acids, emulsification of fat, the breakdown of triglycerides, the formation of mono- and diglycerides, the breakdown of starch and disaccharides, the breakdown of protein, the absorption of monosaccharides, amino acids, iron, calcium, zinc, magnesium. In the jejunum - the breakdown of disaccharides; absorption of monosaccharides, monoglycerides, bile acids, fat-soluble vitamins, folate, calcium, iron, magnesium, zinc, vitamin B12. In the ileum - absorption of bile salts, water, sodium, the main amount of vitamin B 12. In the large intestine - absorption of water, potassium, sodium, calcium, bile salts.

An important digestive organ in the body is the pancreas (PG), which performs an exocrine function. When food enters the gastrointestinal tract, the pancreas secretes into the small intestine not only pancreatic enzymes, but also bicarbonates, which neutralize hydrochloric acid and maintain an alkaline environment in the duodenum, which is necessary for the normal functioning of pancreatic enzymes. Under physiological conditions, the pancreas produces from 50 to 2500 ml of secretion per day, depending on the age of the person and the nature of the incoming food. Pancreatic juice is a colorless alkaline liquid (pH 7.8-8.4). It contains organic substances (proteins) and inorganic components (bicarbonates, electrolytes, trace elements), as well as mucus from the excretory ducts. The enzymatic part of the secret is formed in acinar cells, and the liquid (water-electrolyte) - mucin and bicarbonates - by the ductal epithelium. With the help of pancreatic enzymes (lipases, amylases and proteases), which play a key role in the exocrine function of the pancreas, the breakdown of nutrients occurs. Most of them are in an inactive form - these are proenzymes that are activated in the duodenum by enterokinase. In the active form, lipase, amylase and ribonuclease are secreted. This mechanism determines the activity of pancreatic juice in the intestinal cavity, which, in turn, protects the pancreatic tissue from autolysis.

The digestive enzymes of the pancreas have their own targets: amylase - α-1,4-glycosidic bonds of starch, glycogen; lipase - triglycerides (formation of di-monoglycerides and fatty acids); phospholipase A - phosphatidylcholine (formation of lysophosphatidylcholine and fatty acids); carboxylesterase - cholesterol esters, esters of fat-soluble vitamins, tri-, di-, monoglycerides; trypsin - internal protein bonds (basic amino acids); chymotrypsin - internal protein bonds (aromatic amino acids, leucine, glutamine, methionine); elastase - internal bonds of proteins (neutral amino acids); carboxypeptidase A and B are the outer bonds of proteins, including aromatic and neutral aliphatic amino acids (A) and basic (B) amino acids from the carboxyl end.

The last four enzymes are secreted by the pancreas in an inactive form (proenzymes) and are activated in the duodenum.

Exocrine dysfunction of the pancreas is observed in various hereditary and acquired diseases and may be due to a violation of the formation of pancreatic enzymes or their activation in the small intestine. Due to dysfunction of the pancreas, accompanied by a deficiency of enzymes, a violation of the digestion of food (maldigestion) and absorption of nutrients (malabsorption) in the intestine develops.

Maldigestion in children is caused by a number of disorders.

• Decreased activity of pancreatic enzymes. It can be caused by chronic or acute pancreatitis, cystic fibrosis, congenital pathology of the pancreas - morphological anomalies of the pancreas (abberant pancreas, annular pancreas, stenosis of the Vater papilla or sphincter of Oddi, cysts, bifurcated pancreas), hereditary syndromes accompanied by congenital pancreatic insufficiency (Shwachman syndrome- Diamond, pancreatic insufficiency syndrome with multiple anomalies, deafness and nanism (Iohanson-Bizzard), pancreatic insufficiency syndrome with bone marrow cell vacuolization and sideroblastic anemia (Pearson); isolated enzymatic deficiency (lipases - Sheldon-Rey syndrome; amylase, trypsin, enterokinase) , as well as trauma to the pancreas, carcinoma of the pancreas, primary sclerosing cholangitis.
• Deficiency of bile acids in the small intestine associated with functional disorders of the biliary tract, hepatitis, liver cirrhosis, biliary obstruction.
• Violation of the synthesis of cholecystokinin caused by damage to the duodenal bulb (chronic duodenitis, chronic gastroduodenitis).
• Inactivation of pancreatic enzymes in the small intestine as a result of intestinal dysbiosis or rapid passage of food.
• Violation of the mixing of enzymes with food chyme associated with gastro- and duodenostasis.

The cause of malabsorption is a violation of the secretion of intestinal enzymes due to disaccharidase deficiency, gastrointestinal form of food allergy, intracellular digestion disorders (celiac disease, Crohn's disease, enteritis, etc.), impaired transport of absorbed substances (exudative enteropathy, lymphoma, tumors, tuberculosis).

It is known that the pancreas has great compensatory capabilities, and violations of pancreatic secretion appear only with severe damage to the gland. There is an opinion that pronounced steatorrhea and creatorrhea in adults develop when the secretion of pancreatic lipase and trypsin is reduced by more than 90%. However, such a threshold has not been established in children.

The causes and mechanisms of development of exocrine pancreatic insufficiency are diverse. There are absolute pancreatic insufficiency, caused by a decrease in the volume of the functioning pancreatic parenchyma, and relative, which may be associated with various diseases of the gastrointestinal tract.

If symptoms suggestive of exocrine pancreatic insufficiency are identified, pancreatic enzyme replacement therapy should be started as early as possible, before malabsorption begins to develop.

Clinical signs of exocrine pancreatic insufficiency are:

• stomach ache,
• decreased appetite,
• flatulence,
• unstable chair,
• steatorrhea,
• nausea,
• recurrent vomiting,
• general weakness,
• weight loss,
• decreased physical activity
• growth retardation (in severe forms).

There are a fairly large number of methods for assessing the digestive capacity of the gastrointestinal tract.

• Determination of the content of pancreatic enzymes in the blood and urine. In acute pancreatitis, the level of amylase in the blood and urine can increase 5-10 times; the level of amylase and lipase in the blood during an exacerbation of chronic pancreatitis can be normal or increase 1-2 times for a short time (from several hours to several days), the determination of elastase-1 in the blood plasma, the level of its increase reflects the severity of pancreatitis. The development of hyperfermentemia depends on the period and severity of pancreatitis.
• Coprological research. It should be recognized that scatological research has not lost its relevance to date and is the most accessible method. It should be carried out before the appointment of pancreatic enzymes to the patient. However, the accuracy of this method is also affected by the state of intestinal motility, the volume of bile secreted into the intestinal lumen, its qualitative composition, the presence of inflammatory processes in the intestine, etc.

In case of indigestion, the following symptoms are revealed: steatorrhea - the presence of neutral fat in the stool (type 1 steatorrhea); fatty acids, soaps (steatorrhea type 2); both (steatorrhea type 3); creatorrhea - may be a sign of a violation of the exocrine function of the pancreas. Normally, there are very few muscle fibers in the feces; amylorrhea - the presence in the feces of a large number of starch grains - indicates a violation of the breakdown of carbohydrates; is rarely detected in patients with pancreatic insufficiency, since starch hydrolysis is practically not disturbed due to the high activity of intestinal amylase. The earliest sign of exocrine pancreatic insufficiency is steatorrhea, creatorrhea appears somewhat later. Amylorrhea is rarely seen in exocrine pancreatic insufficiency.

• The study of the content of pancreatic enzymes in the duodenal secret. The method allows you to determine the type of secretion: normosecretory, hypersecretory, hyposecretory or obstructive. The selected types of secretion reflect a different degree of functional and morphological changes in the pancreas, which allows differential treatment.
• Quantitative determination of fat in feces (faecal lipid profile). This method makes it possible to determine the total amount of fat in faeces, taking into account fat of exogenous (food) origin. Normally, the amount of fat excreted in the feces should not exceed 10% of the fat introduced with food. In diseases of the pancreas, the amount of fat excreted with feces sometimes increases to 60%. The method can be used to clarify the nature of steatorrhea, to evaluate the effectiveness of enzyme therapy.
• Determination of the content of elastase-1 in feces. Elastase-1 is a proteolytic enzyme of the pancreas. It is known that human pancreatic elastase does not change its structure as it passes through the gastrointestinal tract. This method has certain advantages over those used today in the diagnosis of exocrine pancreatic insufficiency (fecal lipidogram, coprogram, determination of chymotrypsin in feces) due to the high specificity of the method (93%), its non-invasiveness and the absence of the effect of enzyme preparations on the results of the elastase test.

For the first time, enzyme preparations in gastroenterological practice began to be used about 100 years ago. Digestive enzymes are now widely used in various gastroenterological pathologies. Despite the variety of manifestations of enzymatic digestive disorders, the main direction of therapy for such patients is enzyme replacement therapy. Currently, a large number of enzyme preparations are used in clinical practice, characterized by a different combination of components, enzyme activity, production method, and release form. When choosing an enzyme preparation in each case, the doctor must first of all pay attention to its composition and the activity of its components.

There are two directions of action of enzyme preparations:

• primary - hydrolysis of food substrates, which is the basis for the appointment of enzymes as replacement therapy for exocrine pancreatic insufficiency;
• secondary - reduction of abdominal pain syndrome (with pancreatitis), dyspepsia (feeling of heaviness, flatulence, belching, stool disorders, etc.).

Indications for the appointment of enzyme therapy are:

• violation of the secretion of pancreatic enzymes;
• syndrome of maldigestion and malabsorption;
• motility disorders of the gastrointestinal tract.

Classification of enzyme preparations

There are the following groups of enzyme preparations.

• Preparations containing pancreatin (pancreatin, penzital, mezim forte, panzinorm forte - H, kreon, pancitrate).
• Preparations containing pancreatin, bile components, hemicellulase and other components (festal, digestal, enzistal, panzinorm forte).
• Herbal preparations containing papain, rice fungus extract and other components (pepfiz, oraza).
• Combined enzymes containing pancreatin in combination with vegetable enzymes, vitamins (wobenzym, phlogenzyme).

Despite the fact that there are currently many pancreatic enzyme preparations in the doctor's arsenal, it is still not always possible to select adequate enzyme replacement therapy in patients with severe forms of pancreatic insufficiency. The instability of many enzymes in an acidic environment remains a serious problem.

Preparations containing pancreatic enzymes can be used both constantly, as replacement therapy, and once, with a high nutritional load. The dose is selected individually and depends on the severity of clinical and laboratory parameters of the exocrine function of the pancreas. The effectiveness of the dose is judged by clinical (disappearance of abdominal pain, normalization of the frequency and nature of the stool) and laboratory parameters (disappearance of steatorrhea and creatorrhea in the coprogram, normalization of triglycerides in the lipid profile of the stool).

Enzyme-containing preparations, along with pancreatin, may contain bile acids, hemicellulase, herbal choleretic components (turmeric), simethicone, etc. ( ). The main indication for the use of this group of drugs in children is dysfunction of the biliary tract (hypomotor dyskinesia). Bile acids and salts increase the contractile function of the gallbladder, normalize the biochemical properties of bile, and also regulate the motility of the large intestine in children with constipation. They should be used during or immediately after meals (without chewing) 3-4 times a day in courses up to 2 months. Enzymes of this group are not used for pancreatitis, as they contain bile components that enhance intestinal motility.

Bile acids, which are part of the preparations, increase pancreatic secretion, choleresis; stimulate intestinal and gallbladder motility.

Under conditions of microbial contamination of the intestine, deconjugation of bile acids occurs, while cyclic adenosine monophosphate of enterocytes is activated with the development of osmotic and secretory diarrhea. Bile acids enter the enteropathic circulation, are metabolized in the liver, increasing the load on it. In addition, bile acids can have a direct damaging effect on the intestinal mucosa.

Hemicellulase provides the breakdown of plant polysaccharides (digestible fiber), reduces gas formation.

Contraindications to the appointment of enzyme preparations containing bile components:

• acute pancreatitis;
• chronic pancreatitis;
• acute and chronic hepatitis;
• diarrhea;
• peptic ulcer of the stomach and duodenum;
• inflammatory bowel disease.

Herbal enzyme preparations containing papain, rice fungus extract and other components can be used to correct exocrine pancreatic insufficiency. They are made from plant materials.

The group of enzyme preparations of plant origin includes:

• nigedase - vegetable lipase ( Nigella damascene) - 20 mg; the drug, due to the absence of proteo- and amylolytic enzymes in its composition, is prescribed in combination with pancreatin;
• orase - a complex of amylolytic and proteolytic enzymes of fungal origin - Aspergillus oryzae (lipase, amylase, maltase, protease);
• pepphysis - fungal diastasis - 20 mg, papain - 60 mg, simethicone - 25 mg;
• solizim - lipase produced by the fungus Penicillum solution (20,000 IU);
• somilase - solizim and mushroom L-amylase;
• Unienzyme - fungal diastasis - 20 mg, papain - 30 mg, simethicone - 50 mg, activated charcoal - 75 mg, nicotinamide - 25 mg;
• wobenzym - pancreatin - 100 mg, papain - 60 mg, bromelain - 45 mg, trypsin - 24 mg, chymotrypsin - 1 mg, rutoside - 50 mg;
• merkenzim - pancreatin - 400 mg, bromelain - 75 units, bile - 30 mg;
• phlogenzym - bromelain - 90 mg; trypsin - 48 mg, rutoside - 100 mg.

Pepfiz, Unienzyme, Wobenzym, Merkenzym and Phlogenzyme contain bromelain, a concentrated mixture of proteolytic enzymes from the extract of fresh pineapple fruit and its branches. The effectiveness of bromelains does not depend on the amount of hydrochloric acid in the stomach (pH 3-8.0).

All of the enzymatic preparations of plant origin listed are contraindicated in patients with fungal and household sensitization, with bronchial asthma (A. A. Korsunsky, 2000). Solizim and somilase should not be prescribed for allergies to penicillin antibiotics.

Enzymes based on plant materials can be used to correct exocrine pancreatic insufficiency, especially in cases where the patient does not tolerate pancreatic enzymes (allergy to pork, beef).

It should be noted that data appeared in the literature indicating a low enzymatic activity of enzymes of plant and fungal origin (75 times less effective than preparations of animal origin), and therefore they are not widely used in pediatric practice.

Simple enzymes (betaine, abomin) do not belong to the group of pancreatic enzymes. Currently, the following drugs with proteolytic activity are registered:

• abomin (combined preparation from the gastric mucosa of calves and lambs);
• acidin - pepsin (in a tablet 1 part of pepsin and 4 parts of betaine hydrochloride; when it enters the stomach, betaine hydrochloride is hydrolyzed and hydrochloric acid is released);
• pepsidil (contains pepsin and peptones);
• pepsin (a proteolytic enzyme derived from the mucous membrane of pigs and lambs).

These drugs are obtained from the gastric mucosa of pigs, calves or lambs. The presence of pepsin, cathepsin, peptidases, amino acids in the preparations promotes the release of gastrin, which is a regulatory polypeptide, and therefore drugs of this group can be prescribed for functional disorders of the gastrointestinal tract, with gastritis with secretory insufficiency, which are relatively rare in older children. These drugs are administered orally during meals.

These drugs should not be prescribed for exocrine pancreatic insufficiency.

The success of therapy for exocrine pancreatic insufficiency depends on many factors. Recent studies have not found significant differences in the effectiveness of hourly intake of enzyme preparations and their use with meals. However, the most convenient and physiological for the patient is the intake of enzyme preparations during meals.

In the case of an adequately selected dose and form of the enzyme preparation, a significant improvement in the patient's condition occurs. The criteria for the effectiveness of treatment is the disappearance of polyfecal matter, the reduction or elimination of diarrhea, the increase in body weight, the disappearance of steatorrhea, amylorrhea and creatorrhea. Creatorrhoea usually disappears first on the background of enzyme therapy. This may be due to the fact that the secretion of pancreatic protease persists somewhat longer than that of lipases.

The dose of the enzyme preparation is selected individually during the first week of treatment, depending on the severity of exocrine pancreatic insufficiency. It is advisable to calculate the dose of the enzyme preparation by lipase should start with small dosages (1000 IU of lipase per kg of body weight per day). If there is no effect, the dose of the drug is gradually increased under the control of scatological studies. In severe exocrine insufficiency, 4000-5000 units of lipase per kg of body weight per day are used in 3-4 doses. The duration of therapy is determined individually. Reception of enzymes is stopped in case of disappearance of clinical and coprological signs of maldigestion and malabsorption.

Reasons for the lack of effect in enzyme therapy:

• insufficient dose of the drug;
• loss of enzyme activity in the preparation due to violation of the shelf life;
• enzyme inactivation in the stomach;
• destruction of enzymes in intestinal dysbacteriosis with high colonization of the stomach and duodenum;
• inactivation of enzyme preparations due to the high "acidification" of the duodenum (to prevent this phenomenon, antacids, H2-histamine receptor blockers are prescribed);
• misdiagnosis (steatorrhea type 2; giardiasis, etc.);
• violation of the drug regimen.

Despite the fact that with the help of enzyme preparations it is possible to significantly reduce the degree of steatorrhea, it is not always possible to achieve its complete and permanent disappearance.

Factors preventing the disappearance of steatorrhea:

• malabsorption syndrome;
• low micellar concentration of bile acids due to the fact that they are deposited in the pathologically acidic contents of the duodenum;
• non-simultaneous release of enzymes from the stomach with food (microtablets or microspheres having a diameter of not more than 2.0 mm are transported from the stomach faster than large-diameter tablets or dragees);
• the sensitivity of lipase to the acidic contents of the stomach (up to 92% of lipase, which is part of "ordinary" enzymes, is easily destroyed by hydrochloric acid).

Ways to overcome the inactivation of the enzyme by gastric juice:

• increasing the dose of the drug;
• the appointment of antacids (it must be remembered that antacids containing calcium or magnesium weaken the action of enzymes);
• the appointment of H 2 blockers of histamine receptors.

Contraindications to the appointment of enzyme preparations:

• acute pancreatitis (first 7-10 days);
• exacerbation of chronic pancreatitis (during the first 3-5 days);
• allergy to products from pork, beef.

At present, thanks to a large selection of pancreatic enzyme preparations, there is a real opportunity for individual correction of digestive disorders in children with exocrine pancreatic insufficiency, functional disorders of the stomach, biliary tract. The appointment of enzyme preparations requires a differentiated approach from the doctor in each specific case - it is necessary to take into account the mechanisms of the development of the disease that led to the disruption of the digestive processes.

N. A. Korovina, doctor of medical sciences, professor
I. N. Zakharova, doctor of medical sciences, professor
RMAPO, Moscow

E.V. Koltsova, Ph.D., N.A. Vashchenkova, Ph.D.
FSUE "GiproNIImedprom"

Enzymes are specific biological catalysts of protein nature, accelerating the course of chemical reactions in cells. Lack of enzyme synthesis or persistent functional insufficiency of the enzyme systems of organs and tissues causes the development of pathological processes. Hereditary enzymopathies are associated with a genetically determined deficiency of one or more enzymes. More than 200 hereditary enzymopathies are known, for which the essence of a gene mutation has been established, errors in the synthesis of the protein molecule of the enzyme have been identified, and the corresponding mutated genes have been mapped on chromosomes. Acquired enzymopathies can be caused by a long-term protein deficiency in the diet, a violation of the biosynthesis of coenzymes in vitamin deficiency, inhibition of the synthesis of metalloenzymes with a low content of the corresponding minerals in the diet.

According to the main direction of action and clinical use, enzyme preparations are divided into the following groups: preparations used in purulent-necrotic processes, preparations with fibrinolytic properties and preparations that improve digestion.

The first group includes trypsin, chymotrypsin, chymopsin, ribonuclease and others. They are used mainly for the treatment of purulent and trophic ulcers, bedsores, as well as for thinning viscous secretions in respiratory diseases (pneumonia, bronchitis).

The second group of enzyme preparations includes fibrinolysin, streptolyase, urokinase, thrombolitin, used to dissolve fresh blood clots.

The third group includes drugs such as pepsin, pancreatin, gastric juice, abomin, as well as various complex drugs such as festal, digestal and others. These drugs are prescribed for insufficiency of the secretory activity of the pancreas, glands of the gastric mucosa and other disorders of the gastrointestinal tract.

In addition to the above groups, medicines that also contain enzymes and have other pharmacological properties are used in medical practice. In the most general form, they can be divided into drugs with antitumor and antiviral activity and drugs that are effective in the treatment of diseases of the cardiovascular system.

For the treatment of neoplastic diseases, plant enzymes and a complex of animal and plant enzymes were previously proposed; currently, asparaginase is mainly used for the treatment of leukemia. Drugs for the treatment of the cardiovascular system are of particular importance. The drug cytochrome C, which is scarce in Russia, is produced in a number of countries for the treatment of cerebrovascular accidents and coronary atherosclerosis, neonatal aphyxia. The drug is able to improve tissue respiration in case of violations of the oxidative process in tissues, and the presence of an antihypoxic effect and the absence of side effects make it especially significant.

In the Russian Federation, the production of enzyme preparations is carried out at 14 enterprises of the medical industry, however, the volume and range of products produced are insignificant. The largest share of the range of enzyme preparations is produced by FSUE NPO Microgen and ICN Leksredstva (table). In 1993, industry enterprises produced enzymes used in purulent-necrotic processes (7 trade names), improve digestion (8 trade names) and proteolysis inhibitors (one trade name).

ENZYME PREPARATIONS IMPROVING DIGESTION

A particularly promising area for the use of enzymes is their use for replacement therapy in the treatment of pathologies of the gastrointestinal tract.

The main advantages of modern dosage forms of gastrointestinal enzyme preparations include the high activity of its constituent enzymes, the ability to optimize not only intestinal, but also gastric digestion.

The global market for digestive enzyme preparations was formed mainly in the 1970s. In terms of their composition and activity, these drugs meet all the requirements of the market for chemical and pharmaceutical products necessary for the treatment of mild and severe forms of diseases of the intestines, stomach, liver, biliary tract, and pancreas. The drugs are used to treat both adults and children, including young children and newborns, in whom digestive disorders are especially common and pose a serious threat to life. But the largest part of the consumers of enzyme preparations are elderly and senile people, who often develop a weakening of the digestive function of the stomach, intestines and pancreas.

A feature of enzyme preparations of gastrointestinal action is the presence in their composition of enzymes of animal origin, included in pancreatin, and enzymes obtained as a result of microbiological synthesis. Most preparations contain bacterial enzymes, mainly used to compensate for food masses in the stomach. Mold and yeast enzymes are also used, which have different substrate specificity, thermolability and spectrum of action. Enzyme preparations of gastrointestinal action differ in composition (the presence of microbial acidic enzymes, pepsin, chymotrypsin, bile), as well as in the activity of microbial enzymes, which varies widely - just like the dose of pancreatin.

Obtaining purified monoenzymatic preparations for applied purposes requires a lot of effort and therefore, for economic reasons, is not practiced by most companies. At the same time, taking into account the ability of microorganisms to produce several enzymes, multi-enzyme compositions are created.

The most commonly used dosage forms in Europe are dragees, less often coated tablets; in Japan, it is most often made in the form of capsules, and children's dosage forms - in the form of granules and powder for addition to the mixture for newborns.

Firms in the leading countries of Japan, the USA, Germany produce dozens of types of medicines containing enzyme preparations that improve digestion. On the Russian market, digestive enzymes are represented by both domestic and imported preparations from 13 countries: Germany, France, Finland, India, Lithuania, Slovenia, Pakistan, Turkey, Hungary, Ukraine, Belarus and even San Marino. The main supplier is Germany, which exports 46% of complex drugs - such as Creon, Pankreoflat, Wobenzym, etc.

According to the data of the State Statistics Committee of Russia, in the structure of the general morbidity of the population of the Russian Federation, diseases of the digestive system account for 8%; the number of patients registered in 2002 amounted to 16 million people, the annual increase in cases is approximately 2%. Of particular concern is the fact that the annual growth in the number of adolescents suffering from indigestion increases by 3.3%.

The range of domestic enzyme preparations that optimize digestion is limited, as is the volume of their production. Thus, the range of domestic enzymes of the group under consideration registered by the Ministry of Health of the Russian Federation includes 22 trade names, and produced (in 2003) - 8 trade names, which indicates a slight saturation of the domestic market with Russian medicines.

Pancreatin (tb p/o), Ferestal (tb p/o) and Abomin (tb) are in the greatest demand among domestic enzyme preparations that improve digestion, as evidenced by the levels of their production and sale.

For 9 months of 2003, 21,721.1 thousand packs were produced. No. 10 tablets and 4.4 thousand packs. No. 10 oral solutions, sales respectively amounted to 21404.5 thousand packs. and 4.7 thousand packs. Comparison of production and sales volumes of food enzymes for 9 months of 2002 and 2003. showed an increase in the production of oral forms of abomin, pancreatin, solutions of equine. At the same time, the release of pepsin solution from the gastric glands of dogs, ferestal tablets significantly decreased, while digestal and pancrenorm were suspended.

ENZYME PREPARATIONS WITH ANTI-INFLAMMATORY ACTION

The world market of chemical and pharmaceutical products includes a variety of anti-inflammatory drugs. More often these are external preparations in the form of ointments and powders for the preparation of solutions. Oral and much less often injectable preparations are widely offered.

External dosage forms of enzyme preparations are mainly used to reduce the inflammatory process in wound and burn lesions, accompanied by tissue necrosis with the formation of scabs, fibrous-necrotic and purulent-fibrin deposits or exudates in the cavities of the pleura, peritoneum, joints, etc. In this connection, enzymes that thin exudates, dissolve fibrin, and have necrolytic properties (trypsin, chymotrypsin, papain) are used. In modern dosage forms in Japan, the enzyme serratopeptidase and trypsin with papain are used. Along with enzymes, preparations may contain antibiotics (eg, neomycin) and painkillers (eg, lidocaine, promethazine), since native enzymes often cause pain when they come into contact with healthy granulation tissue.

In Russia, anti-inflammatory enzyme-containing preparations of animal origin, as well as those obtained from cultures of microorganisms, have also been developed. The range of domestic enzyme preparations for the treatment of purulent-necrotic processes, registered by the Ministry of Health of the Russian Federation, contains 29 trade names of enzyme medicines, mainly for external use: suspensions, solutions, ointments, extracts, lyophilized powders for preparing solutions for topical use. Injectable forms of aprotinin (ingiprol, ingitril), hyaluronidase (lidase, lyrase, nidase), collalizin and immobilized elastoterase (napkins) have been developed and registered. However, not all drugs are currently produced on an industrial scale in the medical industry; in 2003, only seven trade names of medicines were produced.

Among domestic enzyme preparations with anti-inflammatory action, the most popular are lyophilized hyaluronidase powders used to increase tissue permeability and ensure fluid movement in interstitial spaces in arthritis, hematomas, and lupus erythematosus. External dosage forms of this enzyme are recommended for the treatment of inflammatory edema in varicose veins, hemorrhoids, and injuries.

In the pharmaceutical market of Russia, hyaluronidase is represented by preparations in the form of lyophilic powders for the preparation of injection solutions of domestic production (lidase, nidase, lyrase) and medicines under the trade name lidase, supplied from Belarus and Ukraine. The State Register of Medicines also includes Ronidase in the form of a powder for external use, but at present there is no production of this dosage form.

For 9 months of 2003, 899.6 thousand packs were produced. No 10 of hyaluronidase (lydase + lyrase + nidase), which amounted to 72.1% compared to the volume of the drug output for the same period in 2002. A decrease in the production of lydase and nidase by 44.3% and 28.6%, respectively, and a 2.1-fold increase in the release of lyrase were noted. The total volume of sales of hyaluronidase preparations for 9 months of 2003 also decreased and amounted to 957.4 thousand packs. No 10 (77.7%).

The situation in the production of other enzyme preparations used in the treatment of purulent-necrotic pathologies is also ambiguous. Thus, compared with 2002, the output of collalizin and terrilitin increased by 2.2 and 1.4 times, respectively, with a simultaneous increase in sales volumes. At the same time, the volumes of production and sales of amorphous and crystalline trypsin decreased.

OTHER ENZYME PRODUCTS

In Russia, cytochrome C, L-asparaginase, and penicillinase, used in acute allergic reactions and anaphylactic shock caused by drugs of the penicillin group, were developed and even produced, albeit in limited quantities. However, at present, the listed drugs are not produced at the factories of the medical industry.

For the treatment of acute pancreatitis and other indications to reduce the activity of proteolytic and fibrinolytic enzymes, drugs that inhibit proteolysis are used, in particular, ingitril obtained from the lungs of cattle. The drug belongs to the vital and essential medicines and is produced at the enterprises of the Federal State Unitary Enterprise NPO Microgen. The growth rate of production and sales of this drug for 9 months of 2003 was 131% and 102.8%, respectively, compared to the same period of the previous year.

In conclusion, it should be emphasized that enzyme preparations are drugs with low toxicity, are well tolerated by patients for a long time, and side effects caused by enzymes are observed in a small number of patients and quickly disappear after discontinuation of the drugs. The use of enzymes for medicinal purposes is a developing direction and occupies an obligatory place in modern complex therapy. In countries with a developed biochemical industry, dozens of enzyme-containing drugs with a diverse spectrum of action are produced. For the Russian Federation, it is economically feasible, in our opinion, not an uncontrolled increase in the number of enzyme medicines, but the replacement of obsolete more modern drugs that meet the requirements of the world market of chemical and pharmaceutical products in order to meet the demand of the country's population and reduce import supplies.

Preparations containing digestive enzymes are currently widely used in the treatment of diseases of the gastrointestinal tract. The main direction in the treatment with enzymes is substitution therapy for insufficiency of one's own enzymes. There are two directions of action of enzyme preparations: 1. splitting food with exocrine pancreatic insufficiency, 2. reducing abdominal pain in diseases of the stomach and intestines, dyspepsia (feeling of heaviness, bloating, belching, stool disorders).
Indications for the appointment of enzymes: violation of the production and secretion of enzymes by the pancreas, violation of intestinal absorption, violation of the motor activity of the gastrointestinal tract.

Classification of enzyme preparations.

1. Preparations containing pancreatin(penzital, pancreatin, mezim forte, pancitrate, creon, pancreoflat, pangrol, pancreon). Indications for the appointment of enzyme preparations containing pancreatin are various conditions accompanied by a violation of the exocrine function of the pancreas, dysbiosis, in which own enzymes are destroyed by microorganisms that seed the small and duodenal intestines, with peptic ulcer with a high content of hydrochloric acid and pepsin in the gastric secretion, with acute infectious and chronic bowel diseases, accompanied by maldigestion and malabsorption syndromes (difficult parietal intestinal digestion and absorption), congenital enzyme deficiency.

2. Preparations containing pancreatin, bile components, hemicellulase and other components(festal, digestal, panzinorm, enzistal, ipental, kadistal, kotazim forte, menzim, pankurmen, pankral). Bile acids, which are part of the preparations, increase the secretion of the pancreas, the motor activity of the intestines and gallbladder. Hemicellulase increases the breakdown of complex sugars of plant origin, reduces gas formation. Combined preparations are prescribed with the predominance of constipation, flatulence, belching, accompanying acute and chronic intestinal pathologies, dysbacteriosis.
Contraindications for the appointment of combined preparations with bile components are pancreatitis (acute and chronic), hepatitis, diarrhea, peptic ulcer of the stomach and duodenum, inflammatory bowel disease.

3. Herbal preparations containing rice fungus extract, papain and other components(pepfiz, orase, nigedase, solizim, somilase, unienzyme). They are used for insufficiency of the exocrine function of the pancreas and for intolerance to beef or pork.
Solizim and somilase are contraindicated in case of allergy to penicillin antibiotics.

4. Combined preparations in which pancreatin is combined with plant enzymes, vitamins(wobenzym, phlogenzym, merkenzym). Herbal preparations are contraindicated in bronchial asthma, allergies to fungi and household dust.
Herbal preparations are 75 times less effective than preparations based on animal enzymes.

5. Simple Enzymes(abomin, betaine) have proteolytic activity and do not belong to pancreatic enzymes. Currently used less.
Abomin is a preparation from the gastric mucosa of calves and lambs, acidin-pepsin based on pepsin and betaine, pepsidil contains pepsin and peptones, pepsin is obtained from the mucous membrane of pigs and lambs. The presence of pepsin, cathepsin, peptidases, amino acids in these preparations promotes the release of gastrin, which increases gastric secretion and motor activity of the gastrointestinal tract. Preparations of this group are prescribed for gastritis with secretory insufficiency.

Enzyme preparations can be used both once (with a significant food or alcohol load), and for long-term treatment. The effectiveness of the drug is indicated by the normalization of the patient's condition (disappearance of pain, normalization of the frequency and nature of the stool) and laboratory changes (normalization of elastase in the feces).
Doses of enzymes are selected individually in terms of lipase activity.
The reasons for the lack or decrease in the effect of treatment with enzymes may be inadequate doses of the drug, inactivation of the enzyme in the stomach, destruction of enzymes during intestinal dysbacteriosis
It is possible to reduce the inactivation of enzymes by gastric juice by simultaneously prescribing H2 blockers of histamine receptors or antacids.

Self-administration of enzyme preparations is possible once during food overload, since long-term therapy requires the correct calculation and selection of dosages, as well as adequate monitoring of clinical and laboratory changes. In addition, prolonged uncontrolled intake of enzyme preparations, especially in high dosages, can suppress the activity of one's own secretion glands.