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An update on the use of proteolytic enzymes as a means to reduce inflammation and pain.

The therapeutic application of orally administered proteolytic enzymes, including pancreatin, bromelain, papain, trypsin, and alpha-chymotrypsin, is well documented by numerous studies based upon physiologic, biochemical, and clinical grounds. Among their actions, proteolytic enzymes possess anti-inflammatory properties, the ability to enhance, and regulate immune functions, and offer support to the circulatory system. Supplementation with proteolytic enzymes reduces inflammation via the neutralization of bradykinins, and pro-inflammatory eicosanoids to a level compatible with synthesis, repair, and regeneration of injured tissues. (1) Additionally, "numerous alterations of cytokine composition" are noted to result with the use of proteolytic enzyme therapy. (2)

Although inflammation is a beneficial component in the healing process, it can become a self-perpetuating process, and in excessive amounts can be a retardant to the healing process. Functionally, proteolytic enzymes break peptide bonds in proteins with "varying degrees of specificity". (1) However, the beneficial action of the use of proteolytic enzymes is that they will not completely inhibit all phases of the inflammatory cascade, thus will not deter the normal healing process.

Aside from the other therapies available for reducing pain, and inflammation, the proteolytic enzymes pancreatin, bromelain, papain, lipase, amylase, trypsin, and chymotrypsin have all demonstrated anti-inflammatory properties in acute models of inflammation. For example in one study chymotrypsin, (5, 18 and 36 mg/kg), trypsin (1.44, 2.88 and 5.76 mg/kg), and serratiopeptidase (0.45, 0.9 and 2.70 mg/kg) were demonstrated in a dose-dependent manner to act in an anti-inflammatory manner in a model of acute inflammation. (3) More detail on the above noted proteolytic enzymes will be discussed below.

Pancreatin: Pancreatin is a digestive enzyme normally produced by the pancreas. In healthy individuals, the pancreas secretes about 8 cups of pancreatic juice into the duodenum on a daily basis. This fluid is a mixture of pancreatic enzymes possessing digestive capabilities, including amylase, lipase, and protease, which function to assist in food digestion. Pancreatin possess proteolytic activity as confirmed by one study in which pancreatin was demonstrated to "completely remove biofilms of Staphylococcal strains producing no or very little Poly-N-acetylglucosamine (PNAG)." (4) PNAG is noted as a major component of biofilms, and via the "depolymerisation of PNAG", confirmed in this study, the biofilms were efficiently removed. (4) This activity was linked to the proteolytic activity of the Pancreatin.

Trypsin & Chymotrypsin: Chymotrypsin and trypsin both function as serine proteases, and like pancreatin, both possess proteolytic actions. These actions have been documented by a number of studies. For example one study demonstrated a significant suppression of inflammation in a dose dependent manner with the use of chymotrypsin and trypsin, along with serratiopeptidase. (3) Utilizing an animal model of induced granuloma formation, the animals were treated with the above noted enzymes. Treatment was demonstrated to result in a significant reduction in ulcer index, as compared to control. (3) Specifically, a 41.88% inhibition of granuloma formation with Chymotrypsin and a 35.85% inhibition with Trypsin was noted, which was compared to a 39.24% reduction with aspirin alone, and no inhibition noted with the control. (3) A separate study noted that proteolytic enzymes including trypsin and chymotrypsin induced "a dramatic stimulation of neutrophil apoptosis", which was determined by various cellular characteristics, including cell morphology, cell DNA content, and the presence of a characteristic DNA fragmentation pattern. This particular study proposed that by virtue of the "selective stimulation of neutrophil apoptosis" that "proteolytic enzymes may play an important role in the normal resolution of inflammation by limiting the autotoxic potential of the neutrophil." (5)

Still another study noted beneficial characteristics with the use of trypsin and chymotrypsin in sepsis. (6) Sepsis is associated with neutrophil influx, and is noted to result in organ failure resulting in approximately six million deaths per year worldwide. According to the above noted study, in sepsis neutrophils exhibit "a supranormal adherence to endothelial monolayers treated with pro-inflammatory cytokines." Neutrophils have also been noted to contribute to sepsis in models of organ failure. (7) Proteolytic enzymes, specifically trypsin and chymotrypsin, used in this situation were demonstrated to improve organ function by virtue of the removal of the neutrophils from circulation, thus demonstrating the beneficial action of these proteolytic enzymes in such circumstances.

Bromelain: Bromelain, a crude extract from pineapple (Ananas comosus), possesses proteolytic activity that is specifically characterized by an enzymatic designation. This enzymatic designation specifies hydrolases (EC 3), which act on peptide bonds (EC 3.4), function as cysteine endopeptidases (EC 3.4.22), and are derived from the stem of bromelain (EC The factors involved in bromelain's proteolytic action are biochemically only partially characterized. However, a molecular mechanism designating bromelain's anti-inflammatory activity has been recently described as acting via a "selective cleavage of P-selectin glycoprotein ligand-1 (PSGL-1) to reduce P-selectin-mediated neutrophil recruitment." (9) P-selectin is expressed in alpha-granules of activated platelets and granules of endothelial cells, and is the largest of the known selectins. Biochemically, P-selectin is surface-expressed within minutes of endothelial cell stimulation via inflammatory mediators, including histamine, thrombin, or phorbol esters. The expression is short-lived, reaching its peak after only ten minutes. Additional synthesis of P-selectin is brought about within two hours by cytokines such as interleukin-1 (IL-1) or tumor necrosis factor alpha (TNF-[alpha]). (10)

As demonstrated by both in vitro and in vivo studies, bromelain contains compounds that possess fibrinolytic, (22) anti-edemous, antithrombotic, and anti-inflammatory activities. (11) As a consequence of these actions, a varied range of therapeutic benefits have been classified with use (11) including "reversible inhibition of platelet aggregation, sinusitis, surgical traumas, (12) thrombophlebitis (blood clot in the vein), pyelonephriti angina pectoris, and bronchitis." (13) In addition to these actions, the use of bromelain has also been attributed to the enhanced absorption of drugs, principally that of antibiotics. (8,14) In clinical situations, bromelain has been used as an anti-inflammatory agent in the treatment of rheumatoid arthritis, soft tissue injuries, colonic inflammation, chronic pain and asthma. (15,16,17,18,19,20,21) In addition to its proteolytic action, evidence also suggests an immunomodulatory and hormone like activity acting via intracellular signalling pathways. (22) Because bromelain is stable over a wide pH range, it is active over a wide range of the gastrointestinal tract. (22)

Papain--Papain is a plant enzyme found naturally in papaya (Carica papaya L.), and is manufactured from the latex of raw papaya fruits. This enzyme is classified as a cysteine protease enzyme, and it functions to break down organic molecules made of amino acids polypeptides, in a wide pH range. It thus plays a crucial role in diverse biological processes, both in physiological and pathological states. (23) Like bromelain, papain also has a specifically characterized enzymatic designation, that of EC, designating it as a hydrolase (EC 3), which acts on peptide bonds (EC 3.4), functions as a cysteine endopeptidases (EC 3.4.22), and is derived from papain (EC 3A22.2). (24)

Based upon its extensive proteolytic activity towards proteins, short-chain peptides, amino acid esters and amide links, papain's application is applied extensively in the fields of food and medicine. (25) Because of the wide pH range for optimal activity (3.0--9.0), as noted above, papain functions in a wide range of situations, thus it possesses an expansive application range. It is also very stable over a wide temperature range, even elevated temperatures. (26)

The specific action of papain has been noted as a "debris-removing agent", and due to the specificity of the enzyme it does not act on the surrounding tissues. This effect has been attributed to the "lack the [alpha]l-antitripsine plasmatic antiprotease", which serves to prevent proteolysis in healthy tissues. (23,27) Papain also has a robust history in treating sport injuries, trauma, and allergy symptoms. (28) In sports injuries, the use of papain has been noted to result in accelerated healing time, from 8.4 to 3.9 days. (29,28) In allergy symptoms associated with leaky gut, papain has been successfully used to alleviate the allergy symptoms. Likewise, hypochlorhydria, gluten intolerance, allergic sinusitis, headache, and toothache have all significantly benefited with the use of the proteolytic enzyme papain. (30) In addition to these actions, papain also possesses antifungal, antibacterial, and anti-inflammatory properties, (31) and has been utilized as an enzymatic wound debridement agent. (32)

Lipase--Lipase is an enzyme naturally produced and utilized by the body to break down fat molecules. Lipase supports the efficient absorption and utilization of dietary fat, and is a necessary component for proper fat absorption, as it functions with bile from the liver to break down fats. Production of lipase occurs primarily in the pancreas, but it is also produced in the mouth and stomach. A shortage of lipase may result in the lack of necessary fats and fat-soluble vitamins, including vitamins A, D, E, and K. In those with certain disorders including cystic fibrosis, Crohn's disease, and celiac disease the production of lipase may be inadequate to achieve the nutrition needed from food. (33)

Biochemically, "lipases function to primarily catalyze the hydrolysis of ester bonds in water insoluble lipid substrates." (34) Lipase has demonstrated effectiveness in reducing bloating, gas, and fullness following a high fat meal. These symptoms are commonly associated with irritable bowel syndrome (IBS), thus the speculation by some researchers that pancreatic enzymes may aid in the management of IBS symptoms. (33) Lipase is also utilized in remedies containing pancreatin to increase pancreatic, and lypolytic activities. A reduction in the fat levels in stool, and increased digestive function has been documented with the use of lipase. (35)

In pancreatic exocrine insufficiency (PEI), defined "as a reduction in pancreatic enzyme activity in the intestinal lumen to a level that is below the threshold required to maintain normal digestion," (36) it has been established that steatorrhea does not occur until pancreatic lipase output is reduced to 5%-10% of normal output. (37,38) In fact, it has been stated that "patients with untreated PEI not only suffer from impaired quality of life due to steatorrhea, weight loss, abdominal discomfort, and other PEI-related symptoms, but are also highly likely to develop deficiencies of micronutrients and lipid-soluble vitamins. (38,39) As a consequence of these deficiencies, patients are at a high risk of "malnutrition-related complications", including osteoporosis." (38,40,41) Thus lipase may provide beneficial support in such instances. Lipase is also utilized to increase pancreatic or lipolytic activities in cases of insufficiency.

As a precaution, lipase utilized in children under the age of 12, should be recommended and managed by a physician.

Amylase--Amylase is an enzyme that functions to break down carbohydrates (starch) into sugars, making them more easily absorbed by the body. Biochemically, [alpha]-amylases (E.C. are enzymes that catalyze the hydrolysis of internal [alpha]-l,4-glycosidic linkages in low molecular weight starches, such as glucose, maltose, and maltotriose units. (42,43,44,15) In addition to its presence in the body, this enzyme is also found in saliva.

Low levels of amylase are assumed to be associated with obesity and metabolic abnormalities. A deficiency in amylase results in diarrhea due to the effects of undigested starch in the colon. Low levels of serum amylase have also been correlated to a decrease in plasma insulin levels, insulin resistance, obesity, and metabolic abnormalities. (46) Additional correlations with deficiency include decreased levels of basal insulin and insulin secretion, and high occurrences of insulin resistance. In addition to its importance in the body, amylases play an important role in a wide number of industrial processes such as food, fermentation, and pharmaceutical industries. (42)

SOD & Catalase - Superoxide dismutase (SOD) and Catalase are enzymes that function in decelerating lipid peroxidation. SOD is an enzyme found in all living cells. Functionally, it catalyzes the removal of the [O.sup.2-] free radical. It also protects oxygen-metabolizing cells against harmful effects of superoxide free-radicals. Structurally it consists of two subunits of identical molecular weight joined by a disulfide bond. It contains two copper [Cu(II)] and two zinc [Zn(II)] atoms per molecule. (47) Likewise, catalase is a heme containing key antioxidant enzyme in the body that defends against oxidative stress. (48) It functions to convert the reactive oxygen species hydrogen peroxide to water and oxygen, and thus mitigates the toxic effects of hydrogen peroxide. (49)

In the body, Copper-zinc superoxide dismutase (CuZnSOD, SOD1 protein) is an abundant copper- and zinc-containing protein. It is present in all human cells in various locations, including the cytosol, nucleus, peroxisomes, and mitochondrial intermembrane space. (50) Its primary function is to act as an antioxidant enzyme, lowering the steady-state concentration of superoxide. If mutated it can also result in disease. According to Valentine JS, et al., "over 100 different mutations have been identified in the sod 1 genes of patients diagnosed with the familial form of amyotrophic lateral sclerosis (fALS)." (50)

Taken in combination, enzyme mixtures have a number of therapeutic advantages, as opposed to the use of a single enzyme. Additionally, the combination of enzymes from diverse sources (animal, plant, fungal) also has a number of advantages including; 1) a wider range of optimal pH, 2) synergism of the combined enzymes, 3) increased percentage of absorption, 4) increase level of effectiveness, and 5) a broader range of application." Additionally, as designated by Streichhan (51), enzyme combinations offer specific advantages due to the fact that:

* "Isoenzymatic activity differences of single biocatalysts are more readily balanced by combining uniformly acting hydrolases of varying origins

* Giant molecular substrates are more quickly and more intensively fragmented by a multihydrolytic preparation because the differently acting hydrolases are able to simultaneously disintegrate the giant molecular substrates at many different locations

* Certain enzymatic mixtures have a broader range of action than pancreatin, bromelain, or any other standardized monohydrolytic preparation - this is because certain enzyme mixtures characteristically possess differences in optimal pH and also differences in reactive properties of the proteo-, lipo-, and/or glycolytic acting hydrolases." (52)

About the Author:

Dr. Rachel Olivier serves as a Physician Advisor for Biotics Research Corporation, a position she has held for over thirteen years. As a Physician Advisor she serves to educate and provide professional leadership for physicians and practitioners, in an effort to improve product understanding. She serves as Biotics ' main consultant, advisor and technical expert, and also writes technically oriented papers, training curriculum, and product support material for practitioners and members of the sales team. In addition to this role, she also maintains a part-time nutritional practice, Healthstone Wellness, where she guides patients on lifestyle interventions and provides nutritional consultations. She holds a Masters degree in Molecular Biology from University of Southwestern Louisiana (currently the University of LA), along with a traditional Naturopathic Degree from Honolulu University, and a PhD in nutrition from California University. She can be contacted at (800) 231-5777 or via email at


(1.) Andersen GD. Dynamic Chiropractic. 1999 17:15

(2.) Leipner J, Iten F, Sailer R. Fherapy with proteolytic enzymes in rheumatic disorders. Biodrugs. 2001:15 (12):779-789.

(3.) Swamy AHMV, P A. Patil PA. Effect of Some Clinically Used Proteolytic Enzymes on Inflammation in Rats. Indian J Pharm Sci. 2008 Jan-Feb; 70(1): 114-117.

(4.) Chaignon P, Sadovskaya 1, Ragunah Ch, Ramasubbu N, Kaplan JB, Jabbouri S. Susceptibility of staphylococcal biofilms to enzymatic treatments depends on their chemical composition. Applied Microbial and Cell Physiology. 2007 75(1):125-132.

(5.) Trevani AS, Andonegui G, Giordano M, Nociari M, Fontan P, Dran G, Geffner JR. Institute of Hematologic Research, National Academy of Medicine, Buenos Aires, Argentina. Neutrophil apoptosis induced by proteolytic enzymes. Laboratory Investigation; a Journal of Fechnical Methods and Pathology. 1996 74(3):711-721.

(6.) Lewis SM, Khan N, Beale R, Freacher DF, Brown KA. Depletion of blood neutrophils from patients with sepsis: treatment for the future? International Immunopharmacology. December 2013 17(4):1226--1232.

(7.) Herter JM, Rossaint J, Spieker T, Zarbock A. Adhesion Molecules Involved in Neutrophil Recruitment during Sepsis-Induced Acute Kidney Injury. J Innate Immun. 2014 6:597-606.

(8.) Maurer HR. Bromelain: biochemistry, pharmacology and medical use. Cellular and Molecular Life Sciences CMLS. August 2001 58(9): 1234-1245.

(9.) Banks JM, Herman CF, Bailey RC. Bromelain decreases neutrophil interactions with PSelectin, but not E-Selectin, in vitro by proteolytic cleavage of P-selectin glycoprotein ligand-1. PLoS One. 2013 Nov 11 8(11):e78988. doi: 10.1371.


(11.) Pavan R, Shraddha SJ, Kumar A. Properties and therapeutic application of bromelain: a review. Biotechnology Research International. Hindawi Publishing Group. 2012. Article ID 976203.

(12.) Livio M, De. Gaetano G, Donati MB. Effect of bromelain of fibrinogen level, protrombin complex and platelet aggregation in the rat-a preliminary report. Drugs under Experimental and Clinical Research. 1978 1:49-53.

(13.) Neubauer RA. A plant protease for potentiation of and possible replacement of antibiotics. Experimental Medicine and Surgery. 1961 19:143-160.

(14.) Renzini G, Varego M. Die resorsption von tetrazyklin ingenenwart von Bromelain bei oraler application. Arzneimittel-Forschung Drug Research. 1972 2: 410--412.

(15.) Taussig, SJ, Batkin S. Bromelain, the enzyme complex of pineapple (Ananas comosus) and its clinical application: An update. Ethnopharmacol. 1988 22:191-203.

(16.) Kelly GS. Bromelain: A literature review and discussion of its therapeutic applications. Altern. Med. Rev. 1996 1:243-257.

(17.) Maurer HR. Bromelain: Biochemistry, pharmacology and medical use. Cell. Mol. Life Sci. 2001 58: 1231-1245.

(18.) Cooreman WM, Scharpe S, Demeester J, Lauwers A. Bromelain, biochemical and pharmacological properties. Pharm. Acta Helv. 1976 4:73-79.

(19.) Izaka KI, Yamada M, Kawano T, Suyama T. Gastrointestinal absorption and anti-inflammatory effect of bromelain. Jpn. J. Pharmecol. 1972 4:519-534.

(20.) Hale LP, Greer PK, Trinh CT, James CL. 2005. Proteinase activity and stability of natural bromelain preparations. Int. Immunopharmacol. 2005 5:783-793.

(21.) Jaber R, 2002. Respiratory and allergic diseases: From upper respiratory tract infections to asthma. Prim. Care. 2002 2:231-261.

(22.) Tochi BN, Wang Z, Xu S-Y, Zhang W. Therapeutic Application of Pineapple Protease (Bromelain): A Review. Pakistan Journal of Nutrition. 2008 7(4): 513-520.

(23.) Amri E, Mamboya F. Papain, a plant enzyme of biological importance: a review. American Journal of Biochemistry and Biotechnology. 2012 8(2):99-104.


(25.) Uhlig H, 1998. Industrial Enzymes and their Applications. 1st Edn., John Wiley and Sons, New York, ISBN-10: 0471196606, pp: 454.

(26.) Cohen LW, Coghlan WM, Dihel LC. Cloning and sequencing of papain-encoding cDNA. Gene. 1986 48:219-227.

(27.) Flindt ML. Allergy to alpha-amylase and papain. Lancet. 1979 1:1407-1408.

(28.) Dietrich RE. Oral proteolytic enzymes in the treatment of athletic injuries: a double-blind study. Pennsyl. Med. J. 1965 68:35-37.

(29.) Trickett P. Proteolytic enzymes in treatment of athletic injuries. Applied Ther. 1964 6:647-652.

(30.) Mansfield KE, Ting S, Haverly RW, Yoo TJ. The incidence and clinical implications of hypersensitivity to papain in an allergic population, confirmed by blinded oral challenge. AnnAllergy. 1985 55:541-543.

(31.) Chukwuemeka NO, Anthoni AB. Antifungal effects of pawpaw seed extracts and papain on post-harvest. Carica papaya L. fruit rot. Afri. J. Agri. Res. 2010 5:1531-1535.

(32.) Ramundo J, Gray M. Enzymatic wound debridement. J Wound Ostomy Continence Nurs. 2008 May-Jun 35(3): 273-80.

(33.) University of Maryland Medical Center.

(34.) Stoytcheva M, Montero G, Roumen Zlatev R, Jose Angel Leon and Velizar Gochev. Analytical Methods for Lipases Activity Determination: A Review. Current Analytical Chemistry. 2012 8:400-407.

(35.) Mackie RD, Levine AS, Levitt MD. Malabsorption of starch in pancreatic insufficiency. Gastroenterol. 1981 80:1220.

(36.) Lindkvist B. Diagnosis and treatment of pancreatic exocrine insufficiency. World J Gastroenterol. 2013 November 14; 19(42): 7258-7266.

(37.) DiMagno EP, Go VL, Summerskill WH. Relations between pancreatic enzyme ouputs and malabsorption in severe pancreatic insufficiency. N Engl J Med. 1973 288: 813-815.

(38.) Drewes, AM. Diagnosis and treatment of pancreatic exocrine insufficiency. World J Gastroenterol. 2013 November 14 19(42):7258-7266.

(39.) Lindkvist B, Dominguez-Muhoz JE, Luaces-Regueira M, Castineiras-Alvarino M, Nieto-Garcia L, Iglesias-Garcia J. Serum nutritional markers for prediction of pancreatic exocrine insufficiency in chronic pancreatitis. Pancreatology. 2012 12:305-310.

(40.) Tignor AS, Wu BU, Whitlock TL, Lopez R, Repas K, Banks PA, Conwell D. High prevalence of low-trauma fracture in chronic pancreatitis. Am J Gastroenterol. 2010; 105: 2680-2686.

(41.) Sikkens EC, Cahen DL, Koch AD, Braat H, Poley JW, Kuipers EJ, Bruno MJ. The prevalence of fat-soluble vitamin deficiencies and a decreased bone mass in patients with chronic pancreatitis. Pancreatology. 2013; 13: 238-242.

(42.) de Souza PM, de Oliveira Magalhaes P. Application of microbial [alpha]-amylase in industry - A review. Braz J Microbiol. 2010 Oct-Dec; 41(4): 850-861.

(43.) Gupta R, Gigras P, Mohapatra H, Goswami VK, Chauhan B. Microbial [alpha]-amylases: a biotechnological perspective. Process Biochem. 2003 38:1599-1616.

(44.) Kandra L. [alpha]-Amylases of medical and industrial importance. Journal of Molecular Structure (Theochem) 2003 666-667:487-98.

(45.) Rajagopalan G, Krishnan C. Alpha-amylase production from catabolite derepressed Bacillus subtilis KCC 103 utilizing sugarcane bagasse hydrolysate. Bioresour Technol. 2008 99:3044-3050.

(46.) Muneyuki T, Nakajima K, Aoki A, Yoshida M, Fuchigami H, Munakata H, Ishikawa S, Sugawara H, Kawakami M, Momomura S, Kakei M. Latent associations of low serum amylase with decreased plasma insulin levels and insulin resistance in asymptomatic middle-aged adults. Cardiovasc Diabetol.2012 11:80. Published online 2012 June 29.




(50.) Valentine JS, Doucette PA, Zittin Potter S. Copper-zinc superoxide dismutase and amyotrophic lateral sclerosis. Annu Rev Biochem. 2005;74:563-93.

(51.) Streichhan P. Wobenzyme[R]. An orally administered combination preparation consisting of hydrolytic enzymes and rutin acting in circulating body fluids. Inventory text Part A, Preclinical results. Geretsried: Mucos Pharma GmbH & Co. 1993.

(52.) Pizzorno JE, Murray MT. Textbook of Natural Medicine. Second Edition. Chruchhill Livingston 1999 Volume 1 pp. 864.

by: Rachel Olivier, MS, ND, PhD
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