Pancreatogenic Diabetes, 2 Onset Forms and Lack of Metabolic Syndrome Components Differentiate It From Type 2 Diabetes

Efficacy and safety of continuous glucose monitoring on glycaemic control in patients with chronic pancreatitis and insulin-treated diabetes: A randomised, open-label, crossover trial

AIMS

Continuous glucose monitoring (CGM) improves glycaemic control and reduces hypoglycaemia in type 1 and 2 diabetes, but its role in managing diabetes in chronic pancreatitis is unknown. We aimed to investigate the effect of CGM compared to self-monitoring of blood glucose (SMBG) on hypoglycaemia and glycaemic control in patients with chronic pancreatitis and insulin-treated diabetes.

MATERIALS AND METHODS

In a randomised, open-label, crossover trial, 30 participants with chronic pancreatitis and insulin-treated diabetes were randomised to 50 days of CGM or SMBG, separated by a 20-day washout period. The primary endpoint was time in level 2 hypoglycaemia (<3.0 mmol/L). Secondary endpoints included additional CGM metrics, HbA1c, daily insulin dose, questionnaires, and safety outcomes.

RESULTS

Twenty-nine participants completed the trial (mean age 64.4 ± 8.8 years; 22 men [75.9%]). There was a numerical reduction in time spent in level 2 hypoglycaemia with CGM compared to SMBG (mean difference -0.36%, 95% confidence interval (CI) -0.78% to 0.06%; p = 0.09). CGM improved time in range (3.9-10.0 mmol/L; mean difference 7.46%, 95% CI 1.67% to 13.25%; p = 0.01), reduced time above range (>10.0 mmol/L; mean difference -6.55%, 95% CI -12.59% to -0.51%; p = 0.04), and reduced time below range (<3.9 mmol/L; mean difference -0.91%, 95% CI -1.79% to -0.03%; p = 0.04) compared to SMBG. No differences were observed for the safety endpoints.

CONCLUSIONS

In patients with chronic pancreatitis and insulin-treated diabetes, CGM increased time in range and reduced time above and below range. These findings highlight the potential of CGM in improving glycaemic control.

Glycemic Variability in Pancreatogenic Diabetes Mellitus: characteristics, Risks, Potential Mechanisms, and Treatment Possibilities

In recent years, pancreatogenic diabetes mellitus has garnered significant attention due to its high incidence, complications, and mortality rates. Glycemic variability (GV) can increase the risk of pancreatogenic diabetes mellitus and its associated complications; however, the precise mechanism remains unclear. The effective control of GV is crucial for preventing the onset of pancreatic diabetes mellitus and improving prognosis. Both diet and antidiabetic medications have substantial effects on GV. However, many patients are prescribed suboptimal or even harmful drugs. Therefore, to provide a comprehensive treatment basis for clinicians to prevent and treat pancreatogenic diabetes mellitus, this study aimed to elucidate the relationship between GV and pancreatogenic diabetes mellitus; investigate the potential mechanisms (such as oxidative stress, inflammatory response, insulin resistance, and lipid metabolism disorders); provide lifestyle guidance; and recommend drug selections to reduce the GV in patients with pancreatogenic diabetes mellitus.

Healthcare disparities in pancreatitis: knowledge gaps and next steps

PURPOSE OF REVIEW

This review examines current research on healthcare disparities in pancreatitis, identifies knowledge gaps, and proposes strategies to develop targeted multilevel interventions to address inequities in pancreatitis care.

RECENT FINDINGS

Current literature has identified patient, disease, and healthcare-level factors contributing to disparities in risk factors and health outcomes of pancreatitis. Moreover, social structures, economic systems, social vulnerability, and policy significantly influence the pancreatitis care continuum.

SUMMARY

Understanding the root causes of health inequities is critical to developing effective approaches for the prevention, early detection, and management of pancreatitis.

Challenges of Managing Type 3c Diabetes in the Context of Pancreatic Resection, Cancer and Trauma

Type 3c diabetes mellitus (T3cDM), also known as pancreatogenic or pancreoprivic diabetes, is a specific type of DM that often develops as a result of diseases affecting the exocrine pancreas, exhibiting an array of hormonal and metabolic characteristics. Several pancreatic exocrine diseases and surgical procedures may cause T3cDM. Diagnosing T3cDM remains difficult as the disease characteristics frequently overlap with clinical presentations of type 1 DM (T1DM) or type 2 DM (T2DM). Managing T3cDM is likewise challenging due to numerous confounding metabolic dysfunctions, including pancreatic endocrine and exocrine insufficiencies and poor nutritional status. Treatment of pancreatic exocrine insufficiency is of paramount importance when managing patients with T3cDM. This review aims to consolidate the latest information on surgical etiologies of T3cDM, focusing on partial pancreatic resections, total pancreatectomy, pancreatic cancer and trauma.

Metformin treatment is associated with reduced risk of hypoglycaemia, major adverse cardiovascular events, and all-cause mortality in patients with post-pancreatitis diabetes mellitus: a nationwide cohort study

OBJECTIVE

Post-pancreatitis diabetes mellitus (PPDM) is a frequent complication of pancreatitis and is associated with an increased risk of adverse outcomes. Metformin is recommended for the treatment of PPDM, but evidence of its risk-benefit profile is limited. In a pharmaco-epidemiologic study, we investigated the association between metformin treatment and adverse outcomes in patients with PPDM.

DESIGN AND METHODS

In a Danish nationwide population-based cohort study, we included adults (≥18 years) with incident PPDM or type 2 diabetes between 2009 and 2018. Post-pancreatitis diabetes mellitus was categorised into acute and chronic subtypes (PPDM-A and PPDM-C). Associations between metformin treatment and severe hypoglycaemia, major adverse cardiovascular events (MACE), and all-cause mortality were examined across the diabetes subgroups using Cox regression analysis. Treatments with metformin, insulin, and other glucose-lowering therapies were handled as time-varying exposures.

RESULTS

We included 222 337 individuals with new-onset type 2 diabetes and 3781 with PPDM, of whom 2305 (61%) were classified as PPDM-A and 1476 (39%) as PPDM-C. Treatment with metformin was associated with a lower risk of severe hypoglycaemia (adjusted hazard ratio [HR] 0.41, 95% CI 0.27-0.62, P < .0001), MACE (HR 0.74, 95% CI 0.60-0.92, P = .0071), and all-cause mortality (HR 0.56, 95% CI 0.49-0.64, P < .0001) in patients with PPDM. In sensitivity analyses and among individuals with type 2 diabetes, metformin treatment exhibited comparable trends of risk reduction.

CONCLUSIONS

Metformin is associated with a lower risk of adverse outcomes, including all-cause mortality in patients with PPDM, supporting the use of metformin as a glucose-lowering therapy for these patients.

Diabetes of the Exocrine Pancreas: Implications for Pharmacological Management

Post-pancreatitis diabetes mellitus, pancreatic cancer-related diabetes, and cystic fibrosis-related diabetes are often underappreciated. As a result, a substantial proportion of people with these sub-types of diabetes receive antidiabetic medications that may be suboptimal, if not harmful, in the context of their underlying disease of the exocrine pancreas. The present article delineates both classical (biguanides, insulin, sulfonylureas, α-glucosidase inhibitors, thiazolidinediones, and meglitinides) and newer (glucagon-like peptide-1 receptor agonists, amylin analogs, dipeptidyl peptidase-4 inhibitors, sodium-glucose co-transporter-2 inhibitors, D2 receptor agonists, bile acid sequestrants, and dual glucagon-like peptide-1 receptor and glucose-dependent insulinotropic polypeptide receptor co-agonists) therapies and provides recommendations for managing people with diabetes of the exocrine pancreas based on the most up-to-date clinical evidence. Also, several emerging directions (lipid-enriched pathways, Y4 receptor agonism, glucagon-like peptide-1 and glucagon receptor co-agonism) are presented with a view to informing the process of new drug discovery and development.

Pancreatic cancer, autoimmune or chronic pancreatitis, beyond tissue diagnosis: Collateral imaging and clinical characteristics may differentiate them

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies and is developing into the 2^nd leading cause of cancer-related death. Often, the clinical and radiological presentation of PDAC may be mirrored by other inflammatory pancreatic masses, such as autoimmune pancreatitis (AIP) and mass-forming chronic pancreatitis (MFCP), making its diagnosis challenging. Differentiating AIP and MFCP from PDAC is vital due to significant therapeutic and prognostic implications. Current diagnostic criteria and tools allow the precise differentiation of benign from malignant masses; however, the diagnostic accuracy is imperfect. Major pancreatic resections have been performed in AIP cases under initial suspicion of PDAC after a diagnostic approach failed to provide an accurate diagnosis. It is not unusual that after a thorough diagnostic evaluation, the clinician is confronted with a pancreatic mass with uncertain diagnosis. In those cases, a re-evaluation must be entertained, preferably by an experienced multispecialty team including radiologists, pathologists, gastroenterologists, and surgeons, looking for disease-specific clinical, imaging, and histological hallmarks or collateral evidence that could favor a specific diagnosis. Our aim is to describe current diagnostic limitations that hinder our ability to reach an accurate diagnosis among AIP, PDAC, and MFCP and to highlight those disease-specific clinical, radiological, serological, and histological characteristics that could support the presence of any of these three disorders when facing a pancreatic mass with uncertain diagnosis after an initial diagnostic approach has been unsuccessful.