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Successfully managing EPI, Exocrine Pancreatic Insufficiency is all about finding the right balance of :

                                                                                               ? Enzymes
? Diet
? Antibiotics (if needed for SIBO)
? B12 (if needed for low or low-normal B12)

? The most effective enzymes are the porcine “powdered” enzymes called pancreatin. Enzyme pills are usually less effective and need to be crushed, plant-based enzymes are not potent enough, enteric coated capsules will work but may require trial and error to determine proper dosage.

? Effective ?average? USP Units for enzyme potency in powdered pancreatin used for EPI in the USA:
33,600 to 71,400 USP of Lipase (needed to digest fats and oils)
280,000 to 495,000 USP of Protease (needed to digest proteins)
280,000 to 495,000 USP of Amylase (needed to digest carbohydrates)

? The best dose recommendation for powdered enzymes is 1 level teaspoon of powdered enzymes per 1 cup of dry kibble, ¾ level teaspoon of powdered enzymes per 1 cup of wet (or raw) food. Not per meal! This dose may slightly from one dog to another.

? Always add approximately 25% of lukewarm liquid (water or broth) per cup of food and let sit for 20 minutes (incubate) to:
? soften the food so the enzymes can be better distributed amongst food particles allowing for greater nutrient absorption and
? help avoid possible mouth sores from the caustic attributes of the powdered enzymes.

? Although incubation is not necessary for all EPI dogs, many EPI dogs do much better once this extra step is taken.

Mix enzymes with room temperature or slightly warm ingredients. Mixing the enzymes with cold food or liquid will inactivate the enzymes and not allow them to start working. Using hot (above 130 degrees F) food or liquid will kill the enzymes too quickly for them to do their job. Microwaving or cooking with the enzymes should be avoided.

? In countries outside the USA, where powdered pancreatin is not readily available but enteric-coated capsules are such as brand name CREON can be used successfully in most cases after some trial and error. Start by giving CREON 10 approximately five minutes prior to a meal. If poor digestion still occurs, start increasing the dose by increments of five. Dosage may vary greatly. Some EPI dogs do well on one CREON 10 with each meal, some need two CREON 10, or one CREON 25. With CREON it depends on the individual dog which dose of CREON will work best.

? Once an EPI dog is stable ?try? reducing the amount of enzymes being used to the lowest dose possible but at a dose that will still allow the dog to properly digest food. This is determined by continued firm stools, minimal volume and elimination frequency equal to that of a normal dog.

? As some dogs age, enzymes supplementation may need to be increased, again, this depends on the individual dog.

This is the trickiest part of managing EPI.

Most EPI dogs respond best to a low fiber diet (check the grain-free foods)Most commercial (over the counter) brand name grain-free foods with less than 4% fiber work as well or better than the prescription diets… unless there is EPI + a concurrent condition such as a food allergy/sensitivity, IBD, etc. However, not all EPI dogs respond equally well to all grain-free dog foods. Finding the right food may involve some trial and error. Some do better on the very high-protein grain-free foods, some do better with mid-range protein foods and some actually need some grain. It all depends on what type of fiber, soluble vs. insoluble and if it is highly or poorly fermentable. It can get very confusing. The majority of EPI dogs do best with soluble (highly digestible fiber) that is low in the poorly fermentable fiber category. Finding the right food really depends on the individual dog.

Feed 150% of what the dog normally would require until the body replenishes the weight that was lost.

Do not restrict fat intake, unless, once again, there is a possible concurrent condition that requires fat restriction. Dogs appear to resume their health quicker when fat % is not restricted as long as they are receiving the proper type and dose of enzymes, and B12 and antibiotics if needed.

Feed smaller portions but more often when first trying to stabilize the dog. Feeding 3 to 4 small meals a day- -at least 2 hours apart to allow for digestion- -is suggested.

? If acid reflux/regurgitation is a problem, try adding 1 teaspoon of canned pure pumpkin to meals, psyllium, or (cimetidine) Tagamet. However, also check to see if a declining B12 level is the culprit. Worse case scenario, use short-term steroids.

? For itchy skin or a dry coat add fish oil,wild salmon oil, krill oil (EFAs suggested at 180mg per 10 lbs per day), or on alternate days give ½ to 1 teaspoon of cold pressed (virgin) coconut oil.

Because of the very nature of EPI (pre-diagnosis/treatment) bad bacteria accumulates and ferments undigested food causing SIBO.

? Although this doesn’t happen often enough ….sometimes when EPI is detected very early on, once proper treatment (enzymes) is administered the good gut flora “may” sometimes re-populate over the bad gut flora (bacteria).

The best way to assess SIBO is by symptoms and accompanying medical ailment, in this case EPI, and treat immediately for best results. Unfortunately, Folate test results, Culturing and Counting bacterial numbers, and Duodenal juice collection all have majors flaws in their technique rendering them inaccurate confirmation of SIBO. Recent studies have determined that it is not the number of bacteria but rather ?the type of flora and/or how the host and flora interact that are more important than numbers.?

Any imbalance in the intestinal bacterial flora is also likely to reduce the absorption of cobalamin (B12).

Treat for possible secondary SIBO especially if the dog displays repeated signs of yellowish-coloring to the stools, continued loose/soft stools, intermittent sloppy stools, gelatinous stool coating, flatulence, lack of appetite, stomach noises, acid reflux, regurgitation, low or low normal B12 (with Tylosin [preferred] or Metronidazole, or Amoxycillin / Oxytetracycline [preferred in the UK]. Or treat with Tylosin for very likely ARD (Antibiotic Responsive Diarrhea or Tylosin Responsive Diarrhea). Tylosin dosage is to be administer twice daily [every 12 hours] with food:
30 lbs – 1/8 tsp
60 lbs – 1/4 tsp
90 lbs – 3/8 tsp
120 lbs – 1/2 tsp

* As of 2010, there is an updated protocol on Tylosin for SIBO. The new recommendation is Tylosin (25 mg/kg BID for 6 weeks) * see on the SIBO page:  HOW I TREAT – SMALL INTESTINAL DYSBACTERIOSIS
Jörg M. Steiner,, PhD, DACVIM, DECVIM-CA
College Station, Texas, USA

A response to the antibiotics should be seen within 7 to 10 days- -if improvement is seen during this time period, indicating that SIBO is present, the antibiotics should be continued for a total of 4 to 6 weeks.

If a positive response is not seen within 7-10 days, change the antibiotic. Most EPI dogs appear to respond best to Tylosin, but if not, switch to Metronidazole (or switch from Metro to Tylan).  ?Some cases never relapse on cessation of treatment, others relapse months later and require a second course of antibiotics. But typically, dogs relapse within days of treatment finishing. In these cases an underlying cause should again be looked for, but ultimately repeated courses or continuous antibiotic therapy may be required. Surprisingly, it may be possible to reduce the dose and dosage interval. “While this is not considered best practice for antibiotic usage, and resistance is likely to develop, in reality it works!.? quoted by Edward J. Hall, Clinical Vet Science,Univ of Briton, Lang ford, Bristol England.
Recently a regimen of reducing an antibiotic protocol while increasing an “agreeable” pre/probiotic regimen has allowed some “antibiotic lifers” to get off of antibiotics completely… Please read the SIBO page for details.

? An inclusion of prebiotics such as fructo-oligosaccharides are logical although not yet proven. Basically, prebiotics are non-digestible food components (dietary fiber) that are being fermented by intestinal bacteria. This can lead to normalization of the intestinal microbiota. In a recent study the use of fructooligosaccharides (FOS) in the diet showed a lasting advantageous effect. While this has not been evaluated as of yet, other prebiotics, such as inulin or beet-pulp may also prove to be beneficial. This syndrome is also a potential target for probiotic therapy but one must be careful when administering probiotics. Per Dr. Jorg Steiner of Texas A&M University ?…unrealistic expectations have been replaced with well-defined requirements for probiotics and controlled studies of their beneficial effects. Three key requirements for a probiotic for use in dogs are:
1) the probiotic must be safe;
2) the probiotic must be stable; and
3) the probiotic must be efficacious.
In a recent study, 8 veterinary and 5 human probiotics were evaluated and only 2 of the 13 products contained the strains and concentrations of those strains indicated on the label. Several of the products contained bacterial species that could potentially act as pathogens. Thus, in order to ensure safety, the probiotic product should adhere to strict production and storage requirements. The probiotic also must be stable throughout transport and storage until the product is being administered by the pet-owner. In order to ensure that a certain number of colonies are administered to the patient, the colonies in the product should neither
proliferate nor die.
 (use a 3rd party lab to verify product ?claims? such as
Finally, a probiotic must be efficacious. In order to be efficacious, the bacteria must reach the intestinal lumen. This requires that the bacterial species being used in the formulation are both acid- and bile-acid resistant. Also, the bacterial species of the probiotic preparation should adhere to the intestinal mucosa to prolong the time of interaction. Finally, the presence of the probiotic species must have beneficial effects in the host. Several controlled studies have been conducted in dogs that also show that certain probiotics carry health benefits in dogs with gastrointestinal disorders.?

B12 (Cobalamin Deficiency)
Cobalamin deficiency occurs in approximately 82% of all EPI dogs.

Treatment is required for low and low-normal B12 levels and treatment should be parenteral vitamin B12.
Generic cobalamin preparations are recommended at 1mg/ml, i.e. 1000?g/ml. Do not use B12 multivitamin or B12 complex as these are not sufficient and will also sting the dog. The conservative dose regimen is one dose weekly for six weeks, then one dose every two weeks for six weeks, then dose monthly. Remeasure serum cobalamin concentrations one month after last administration. The newer, less conservative regimen is dose weekly for 6 weeks, then one dose after 30 days and retest 30 days after the last dose. In either case, if the cobalamin test results are normal.. .CONTINUE dosing until levels are above average range, then determine how often B12 needs to be administered to that particular EPI dog to maintain above mid-range levels. B12 dosage for EPI dogs:
dogs up to 5 kg (10 lb) = 250 ?g
dogs, 5-15kg (10-30 lb) = 400 ?g
dogs, 15-30 kg (30-65 lb) = 800 ?g
dogs, 30-45 kg (65-100 lb) = 1200 ?g
dogs above 45 kg (100 lb) = 1500 ?g

? With some dogs, especially the smaller breeds, there sometimes appears to be some difficulty maintaining B12 levels even with weekly injections. In these cases, although no controlled study has been done yet, when re-tested these dogs manage to ?hold? their B12 levels if supplemented (in-between weekly injections) with specific B12 pills that contain the intrinsic factor. At this time, two brand name pills are known to have the Intrinsic Factor in them:
Metagenics “Intrinsi B12/Folate”
Wonder Laboratories “Trinfac-B Intrinsic Factor”
Another possibility with these difficult cases is to try using a different formulation of cobalamin, such as hydroxocobalamin or Methlycobalamin.

? Since cobalamin is a water-soluble vitamin, excess cobalamin is excreted through the kidneys and clinical disease due to over-supplementation has never been reported.

If a dog has low or low normal B12, in addition to doing the Cobalamin Therapy, also treat for SIBO with antibiotics. Dietary cobalamin is bound to dietery protein (animal protein) digested by pepsin and HCI in the stomach with cobalamin being released which binds to R-protein digested by pancreatic proteases in small intestine and binds to intrinsic factor absorbed through the ileum. EPI destroys the pancreatic protease and this is why only parenteral B12 by bypassing this process or B12 pills with intrinsic factor “appear” to work on EPI cases.

Any imbalance in the intestinal bacterial flora is also likely to reduce the absorption of cobalamin.

This is Fritzy, a Schnauzer, displaying physical EPI symptoms in Sept 2008…. and Fritzy 5 months later, stable, after receiving treatment for EPI.