Table 2.

Pert management summary.

PERT MANAGEMENT SUMMARY
1. Lifestyle modification	Complete cessation of smoking and alcohol consumption.
2. Diet	Recommend a healthy diet; dietary fat restriction is not required. Smaller more frequent meals may improve symptoms.
3. Start with an adequate dose of PERT	30–40,000 IU with each meal and 15–20,000 IU with snacks.
4. Timing is important	PERT should be taken with both meals and snacks; if several capsules are required, they should be taken at various times before, during and after eating.
5. Ensure follow up & assess response	Monitoring response to treatment is important. Careful evaluation for other causes in patients not improving; including pancreatic cancer (EUS, imaging), celiac disease (TTG IgA), giardia (stool antigen), SIBO (breath test), irritable bowel syndrome, and mucosal disease (endoscopy).
6. Step-wise optimization of PERT	a. Assess compliance & reinforce importance of daily dosing with all meals and snacks
	b. Increase the dose of PERT (double the dose)
	c. Trial of concomitant PPI or H2B therapy
	d. Switch formulation