REVIEW · August 04, 2014
TAKE-HOME MESSAGE
- Sales of over-the-counter (OTC) enzymes marketed for inflammatory disorders, multiple sclerosis, pancreatic insufficiency, allergies, burns, infections, and cancer have increased in recent years. This article reviews the evidence of the risks and benefits of OTC enzymes.
- Descriptions for the use, dosage, and adverse effects are given for common OTC enzymes including bromelain, papain, trypsin, and chymotrypsin.
Expert Comment
Primary Care
David Rakel MD, FAAFP
Enzyme supplements and inflammation
Last week we looked at glucosamine and chondroitin for knee arthritis. This week, Mayo Clinic Proceedings published a review of over-the-counter (OTC) enzyme supplements.
In short, Edakkanambeth’s review shows that the evidence for using enzymes for GI distress and cancer is limited at best but appears to be most promising for inflammation related to osteoarthritis (OA). The most studied supplement (due in part to support from the makers of Phlogenzym) includes two enzymes and one flavonoid. The two enzymes are bromelain, which comes from pineapple, and trypsin, which is often harvested from animal glandular pancreases. The flavonoid is rutin, which is used as an antioxidant. The mechanism of action is not completely understood, but it appears to reduce inflammation through the modulation of cytokines.
In a study comparing two tablets three times daily of bromelain 90 mg, trypsin 48 mg, and rutin 100 mg with the NSAID diclofenac 50 mg three times daily for OA of the hip, the enzyme supplement worked just as well in improving pain and function with fewer side effects.1 A similar study was done for knee OA with similar results.2 A larger multicenter study for lateral ankle sprain showed significant improvement (~70%), but the placebo group did just as well (~70%).3
If you have a patient with OA who cannot tolerate NSAIDS, it appears that a combination of bromelain, trypsin, and rutin may work as well as diclofenac, but the placebo effect may be high.
References
1 Klein G, Kullich W, Schnitker J, Schwann H. Efficacy and tolerance of an oral enzyme combination in painful osteoarthritis of the hip. A double-blind, randomised study comparing oral enzymes with non-steroidal anti-inflammatory drugs. Clin Exp Rheumatol. 2006;24(1):25-30.
2 Tilwe GH, Beria S, Turakhia NH, et al. Efficacy and tolerability of oral enzyme therapy as compared to diclofenac in active osteoarthrosis of knee joint: an open randomized controlled clinical trial. J Assoc Physicians India. 2001;49:617-621.
3 Kerkhoffs GM, Struijs PA, de Wit C, et al. A double blind, randomised, parallel group study on the efficacy and safety of treating acute lateral ankle sprain with oral hydrolytic enzymes. Br J Sports Med. 2004;38(4):431-435.
ABSTRACT
Over-the-counter (OTC) enzyme use is increasing in frequency in the United States. The numerous health benefit claims by manufacturers are leading to a surge in enzyme use for various conditions and symptoms. Clinicians need to help patients navigate this complex realm and make informed decisions about the use of OTC enzymes. This review focuses on key concepts for health care providers to understand the current evidence, risks, and benefits of OTC enzymes.
Mayo Clinic Proceedings. Mayo Clinic
Over-the-Counter Enzyme Supplements: What a Clinician Needs to Know
Mayo Clin Proc 2014 Aug 04;[EPub Ahead of Print], J Edakkanambeth Varayil, BA Bauer, RT Hurto