Lactose intolerance medical therapy

Lactose Intolerance Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Lactose Intolerance from Other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
Chest X Ray
CT
MRI
Echocardiography or Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Lactose intolerance medical therapy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Lactose intolerance medical therapy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Lactose intolerance medical therapy
CDC on Lactose intolerance medical therapy
Lactose intolerance medical therapy in the news
Blogs on Lactose intolerance medical therapy
Directions to Hospitals Treating Lactose intolerance
Risk calculators and risk factors for Lactose intolerance medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [7]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46]

Overview

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Medical Therapy

• Pharmacologic medical therapy is recommended among patients with lactose intolerance that do not respond well to lifestyle modifications.
• Pharmacologic medical therapies for loctose intolerance include lactase enzyme preparations such as:
  • Lactaid
  • Lactogest
  • DairyEase
• Lactase enzyme preparations have bacterial or yeast beta-galactosidases
• In secondary lactase deficiency, treatment is based on the underlying cause.

Lifestyle modification

• Patients with lactose intolerance are treated with dietary restriction of lactose and adequate intake of calcium. 
  • Milk and ice cream have highest amount of lactose, but due to high fat concentration and slower rate of gastric emptying rate in ice cream, compared to the milk, the symptoms of lactose intolerance with ingestion of ice cream is very mild.
  • Levels of lactose is much lower in cheeses.

• 1 L of milk (equivalent to 50 grams of lactose) once a day, without any meals, usually cause symptoms in lactose intolerant persons.
• Limitation in lactose intake, the equivalent of 240 ml (8 oz, one cup) of milk or less a day cause less symptoms of lactose intolerance.
• Two cups of milk per day, divided in two doses with food can be tolerated well.
• Patients with lactose intolerance are treated with dietary restriction of lactose and adequate intake of calcium.
  • Milk and ice cream have highest amount of lactose, but due to high fat concentration and slower rate of gastric emptying rate in ice cream, compared to the milk, the symptoms of lactose intolerance with ingestion of ice cream is very mild.
  • Levels of lactose is much lower in cheeses.
• Yoghurt containing live cultures which provides endogenous beta-galactosidase can be used as an alternative to milk products in persons with lactose intolerant.
• Attention to daily ingestion of calcium and vitamin D is necessary . Dietary calcium recommendation for adolescents and adults is 1200–1500 mg. Calcium and vitamin D supplementation should be considered if there are not enogh in diet.

Lactose intolerance

Adult and pediatric

• Lactaid (caplet), DairyEase (chewable tablet), Lactogest (soft gel capsule) : 3,000-9,000 units PO with meals or dairy
• Lactaid drops: 5–15 drops in quart ( 946 ml ) of milk

References

Lactose Intolerance Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Lactose Intolerance from Other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
Chest X Ray
CT
MRI
Echocardiography or Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Lactose intolerance medical therapy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Lactose intolerance medical therapy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Lactose intolerance medical therapy
CDC on Lactose intolerance medical therapy
Lactose intolerance medical therapy in the news
Blogs on Lactose intolerance medical therapy
Directions to Hospitals Treating Lactose intolerance
Risk calculators and risk factors for Lactose intolerance medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [47]

Overview

Lactose intolerance is easy to treat. No treatment can improve the body’s ability to produce lactase, but symptoms can be controlled through diet. The basic principles involved in the management of lactose intolerance include avoiding dietary lactose, substitution of nutrients, using enzyme substitute and regulating calcium intake.

Medical Therapy

Managing Lactose Intolerance

For persons living in societies where the diet contains relatively little dairy, lactose intolerance is not considered a condition that requires treatment. However, those living among societies that are largely lactose-tolerant may find lactose intolerance troublesome. Although there are still no methodologies to reinstate lactase production, some individuals have reported their intolerance to vary over time (depending on health status and pregnancy</nowiki>). Lactose intolerance is not usually an all-or-nothing condition: the reduction in lactase production, and hence, the amount of lactose that can be tolerated varies from person to person. Since lactose intolerance poses no further threat to a person's health, managing the condition consists of minimizing the occurrence and severity of symptoms.

Berdanier and Hargrove recognize 4 general principals:

1. Avoidance of dietary lactose
2. Substitution to maintain nutrient intake
3. Regulation of calcium intake
4. Use of enzyme substitute

Avoiding Lactose-Containing Products

Since each individual's tolerance to lactose varies, according to the US National Institute of Health, dietary control of lactose intolerance depends on people learning through trial and error how much lactose they can handle. Label reading is essential as commercial terminology varies according to language and region.

Lactose is present in 2 large food categories: Conventional dairy products, and as a food additive (in dairy and non dairy products).

Dairy Products

Lactose is a water soluble molecule. In the curdling process lactose is found in the water portion along with whey and casein, but is not found in the fat portion. Therefore fat percentage and the curdling process have a certain impact on which foods may be tolerated. Conversely, low fat dairy foods often have various dairy derivatives such as milk solids added to them to enhance sweetness. Any dairy product which is fat reduced or fat free generally have a slightly higher lactose percentage.

• Milk: Human milk has the highest lactose percentage at around 9%. Unprocessed cow milk has 4.7% lactose. Unprocessed milk from other mammals contains similar lactose percentages (goat milk 4.1%, buffalo 4.86%, yak 4.93%, sheep milk 4.6% ).

• Butter: The butter making process by definition separates milk's water components from the fat components. Lactose, being a water soluble molecule, will not be present in the butter unless milk solids are added to the ingredients.

• Yogurt and Kefir: People can be more tolerant of traditionally made yogurt than milk because it contains some lactase produced by the bacterial cultures used to make the yogurt. However, many commercial brands contain additional milk solids (lactose). Read labels.

• Cheeses: Traditionally made hard cheese (such as Swiss cheese) and soft ripened cheeses may create less reaction than the equivalent amount of milk because of the processes involved. Fermentation and fat content contribute to lesser amounts of lactose. Traditionally made Swiss or Cheddar might contain 10% of the lactose found in whole milk. In addition, the traditional aging methods of cheese (over 2 yrs) reduces their lactose content to practically nothing. Commercial cheese brands are generally manufactured by modern processes that do not have the same lactose reducing properties. Aged cheeses are usually aged for very short periods, and usually no laws mandate what qualifies as an aged cheese. One must read labels carefully.

• Buttermilk, sour cream and ice cream, like yogurt, if made the traditional way, will generally be quite tolerable, but most modern brands add milk solids. Consult labels.

Examples of lactose levels in foods. As scientific consensus has not been reached concerning lactose percentage analysis methods (non-hydrated form or the mono-hydrated form), and considering that dairy content varies greatly according to labeling practices, geography and manufacturing processes, lactose numbers may not be very reliable. The following are examples of lactose levels in foods which commonly set off symptoms. These quantities are to be treated as guidelines only. Read the labels to be sure.

Dairy product	Lactose Content
Yogurt, plain, low-fat, 240 mL	5 g
Milk, reduced fat, 240 mL	11 g
Swiss cheese, 28 g	1 g
Ice cream, 120 mL	6 g
Cottage cheese, 120 mL	2–3 g

Lactose in Non Dairy Products

Lactose (also present when labels state whey, milk solids, modified milk ingredients, etc) as a commercial food additive is used for its texture, flavor and adhesive qualities, and is found in foods such as processed meats (sausages/hot dogs, sliced meats, Pâtés), margarines, sliced breads, breakfast cereals, potato chips, dried fruit, processed foods, medications, pre-prepared meals, meal replacement (powders and bars), protein supplements (powders and bars).

Kosher products labeled pareve are mostly free of milk, however if a "D" is present next to the circled K, the food contains milk solids.

Alternative Products

Milk: The dairy industry has created quality low-lactose or lactose-free products to replace regular dairy. Lactose-free milk can be produced by passing milk over lactase enzyme bound to an inert carrier: once the molecule is cleaved, there are no lactose ill-effects. A form is available with reduced amounts of lactose (typically 30% of normal), and alternatively with almost 0%. Finland has had HYLA (acronym for hydrolysed lactose) products available for many years, even though the number of lactose intolerant people there is relatively small. These low-lactose level cow's milk products, ranging from ice cream to cheese, use a Valio patented chromatographic separation method to remove lactose. The ultra-pasteurization process, combined with aseptic packaging ensures a long shelf-life. Recently, the range of low-lactose products available in Finland has been augmented with milk and other dairy products (such as ice cream, butter, and buttermilk) that contain no lactose at all. The remaining about 20% of lactose in HYLA products is taken care of enzymatically. These typically cost 2 - 4 times more than equivalent products containing lactose. Valio also markets these products in Sweden.

Plant based milks and derivatives are the only ones to be 100% lactose free (soy milk, almond milk, oat milk, rice milk, hemp milk, peanut milk).

Alternatively, bacterium such as L. acidophilus may be added, which affects the lactose in milk the same way it affects the lactose in yogurt.

Lactase Supplementation

When lactose avoidance is not possible, or on occasions when a person chooses to consume such items, then enzymatic lactase supplements may be used.

Lactase enzymes similar to the those produced in the small intestines of humans are produced industrially by fungi of the genus aspergillus. The enzyme, β-galactosidase, is available in tablet form in a variety of doses, in many countries without a prescription. It functions well only in high-acid environments, such as that found in the human gut due to the addition of gastric juices from the stomach. Unfortunately, too much acid can denature it, and it therefore should not be taken on an empty stomach. Also, the enzyme is ineffective if it does not reach the small intestine by the time the problematic food does. Lactose-sensitive individuals should experiment with both timing and dosage to fit their particular need. But supplements such as these may not be able to provide the accurate amount of lactase needed to adequately digest the lactose contained in dairy products, which may lead to symptoms similar to the existing lactose intolerance.

While essentially the same process as normal intestinal lactose digestion, direct treatment of milk employs a different variety of industrially produced lactase. This enzyme, produced by yeast from the genus kluyveromyces, takes much longer to act, must be thoroughly mixed throughout the product, and is destroyed by even mildly acidic environments. It therefore has been much less popular as a consumer product (sold, where available, as a liquid) than the aspergillus-produced tablets, despite its predictable effectiveness. Its main use is in producing the lactose-free or lactose-reduced dairy products sold in supermarkets.

Enzymatic lactase supplementation may have an advantage over avoiding dairy products, in that alternative provision does not need to be made to provide sufficient calcium intake, especially in children.

Rehabituation to Dairy Products

For some people having secondary lactose intolerance and who are otherwise healthy, it may be possible to train bacteria in the large intestine to break down lactose more effectively by consuming small quantities of dairy products several times a day over a couple of weeks. Adding dairy to diets of people who are sick may cause complications and even worsen the disease itself, especially if the dairy intake is not discovered in time as the real cause of the symptoms.

Nutritional Concerns

Primary Lactose Intolerance

Populations where primary lactose intolerance are the norm have demonstrated similar health levels to westerners.

Secondary Lactose Intolerance

While secondary lactose intolerance does not inherently affect an individual's nutritional needs, according to mainstream media and accepted doctrines in western European and North American countries, dairy is an essential part of a healthy diet. Dairy products are relatively good and accessible sources of calcium and potassium and many contries mandate that milk be fortified with vitamin A and vitamin D. Consequently, in dairy consuming societies, dairy is often a main source of these nutrients; and, for lacto-vegetarians, a main source of vitamin B12. Individuals who reduce or eliminate consumption of dairy must obtain these nutrients elsewhere. Asian populations for whom dairy is not part of their food culture do not present with decreased health, and sometimes they present with above average health, like people in Japan.

Plant based milk substitutes are not naturally rich in calcium, potassium, or vitamins A or D (and, like all non-animal products, contain no vitamin B12). However, prominent brands are often voluntarily fortified with many of these nutrients; one should read the label to be certain.

An increasing number of calcium-fortified breakfast foods, such as orange juice, bread, and dry cereal, have been appearing on supermarket shelves. Many fruits and vegetables are rich in potassium and vitamin A; animal products like meat and eggs are rich in vitamin B12, and the human body itself produces some vitamin D from exposure to direct sunlight. Finally, a dietitian or physician may recommend a vitamin or mineral supplement to make up for any remaining nutritional shortfall.

Lactose reduced dairy products have the same nutritional content as their full-lactose counterparts, but their taste and appearance may differ slightly.

Congenital Lactase Deficiency

Before the 20th century, infants with this disease could not survive. Now parents need only supply lactose-free milk and dairy products and the child will then have the same nutritional concerns as people with secondary lactose intolerance.