Pancreatic and gut hormone responses to mixed meal test in post-chronic pancreatitis diabetes mellitus

Risk Factors and Mechanisms for Diabetes in Pancreatitis

Diabetes (DM) can occur as a complication of acute, acute recurrent, or chronic pancreatitis, affecting more than 30% of adults with chronic pancreatitis. Data on the pathophysiology and management are limited, especially in pediatric population. Proposed mechanisms include insulin deficiency, insulin resistance, decreased pancreatic polypeptide, and possible beta-cell autoimmunity (in a small subset). Risk factors for developing diabetes in those with pancreatitis may include hypertriglyceridemia, obesity, necrotizing pancreatitis, exocrine pancreatic insufficiency, and pancreatic calcifications, among others. Further studies are required to understand pathophysiology of pancreatogenic DM, in order to define optimal treatment approaches.

Differential Diagnosis of Post Pancreatitis Diabetes Mellitus Based on Pancreatic and Gut Hormone Characteristics

CONTEXT

Distinguishing different types of diabetes is important in directing optimized treatment strategies and correlated epidemiological studies.

OBJECTIVE

Through detailed analysis of hormone responses to mixed meal tolerance test (MMTT), we aimed to find representing characteristics of post-acute pancreatitis diabetes mellitus (PPDM-A) and post-chronic pancreatitis diabetes mellitus (PPDM-C).

METHODS

Participants with PPDM-A, PPDM-C, type 1 diabetes, type 2 diabetes, and normal controls (NCs) underwent MMTT. Fasting and postprandial responses of serum glucose, C-peptide, insulin, glucagon, pancreatic polypeptide (PP), ghrelin, gastric inhibitory peptide (GIP), glucagon like peptide-1 (GLP-1), and peptide YY (PYY) were detected and compared among different groups. Focused analysis on calculated insulin sensitivity and secretion indices were performed to determine major causes of hyperglycemia in different conditions.

RESULTS

Participants with PPDM-A were characterized by increased C-peptide, insulin, glucagon, and PP, but decreased ghrelin, GIP, and PYY compared with NCs. Patients with PPDM-C showed secretion insufficiency of C-peptide, insulin, ghrelin, and PYY, and higher postprandial responses of glucagon and PP than NCs. In particular, both fasting and postprandial levels of ghrelin in PPDM-C were significantly lower than other diabetes groups. PYY responses in patients with PPDM-A and PPDM-C were markedly reduced. Additionally, the insulin sensitivity of PPDM-A was decreased, and the insulin secretion for PPDM-C was decreased.

CONCLUSION

Along with the continuum from acute to chronic pancreatitis, the pathological mechanism of PPDM changes from insulin resistance to insulin deficiency. Insufficient PYY secretion is a promising diagnostic marker for distinguishing PPDM from type 1 and type 2 diabetes. Absent ghrelin secretion to MMTT may help identify PPDM-C.

Identification of Differential Metabolites Between Type 2 Diabetes and Postchronic Pancreatitis Diabetes (Type 3c) Based on an Untargeted Metabolomics Approach

OBJECTIVE

A nontargeted metabolomics approach was established to characterize serum metabolic profile in type 3c diabetes mellitus (T3cDM) secondary to chronic pancreatitis and compare with T2DM.

METHODS

Forty patients were recruited for metabolite analysis based on liquid chromatography-mass spectrometry. Cluster heatmap and KEGG metabolic pathway enrichment analysis were used to analyze the specific and differential metabolites. The receiver operating characteristics (ROCs) were generated and correlation analysis with clinical data was conducted.

RESULTS

Metabolites including sphingosine, lipids, carnitine, bile acid, and hippuric acid were found to be different between T2DM and T3cDM, mainly enriched in bile acid biosynthesis, fatty acid biosynthesis, and sphingolipid metabolic pathways. The ROCs were generated with an area under the curve of 0.907 (95% confidence interval, 0.726-1) for the model with 15 metabolites.

CONCLUSION

T3cDM is characterized by increased sphingosine, carnitine, bile acid, and most lipids, providing novel biomarkers for clinical diagnosis and a future direction in research on pathophysiological mechanisms.

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.

Pancreatogenic Diabetes in Children With Recurrent Acute and Chronic Pancreatitis: Risks, Screening, and Treatment (Mini-Review)

Up to 9% of children with acute recurrent pancreatitis (ARP) or chronic pancreatitis have pancreatogenic diabetes mellitus (DM), and this risk likely increases as they age into adulthood. Risk factors for pancreatogenic DM in children vary depending on the clinical cohort but may include pancreatic atrophy, exocrine insufficiency, pancreatic calcifications, obesity/metabolic syndrome features, or autoimmune diseases. Knowledge regarding disease pathology is extrapolated nearly entirely from studies in adults. Insulin deficiency is the primary defect, resulting from islet loss associated with pancreatic fibrosis and cytokine-mediated β-cell dysfunction. Beta cell autoimmunity (type 1 diabetes) should also be considered as markers for this have been identified in a small subset of children with pancreatogenic DM. Hepatic insulin resistance, a deficient pancreatic polypeptide state, and dysfunctional incretin hormone response to a meal are all potential contributors in adults with pancreatogenic DM but their significance in pediatrics is yet unknown. Current guidelines recommend yearly screening for diabetes with fasting glucose and hemoglobin A1c (HbA1c). Insulin in the first-line pharmacologic therapy for treatment of pancreatogenic DM in children. Involvement of a multidisciplinary team including a pediatric endocrinologist, gastroenterologist, and dietitian are important, and nutritional health and exocrine insufficiency must also be addressed for optimal DM management.