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Parhiala M, Ukkonen M, Sand J, Laukkarinen J. Osteoporosis and sarcopenia are common and insufficiently diagnosed among chronic pancreatitis patients. BMC Gastroenterol 2023; 23:124. [PMID: 37046204 PMCID: PMC10099896 DOI: 10.1186/s12876-023-02756-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023] Open
Abstract
PURPOSE Chronic pancreatitis (CP) leads to diabetes and pancreatic exocrine insufficiency (PEI). PEI may lead to maldigestion and malnutrition, which may cause fat-soluble vitamin deficiency, sarcopenia and abnormal bone density. We aim to study the prevalence of osteoporosis, sarcopenia and vitamin deficiency among CP patients. METHODS Long-term (4-5 years) follow-up was implemented on CP patients. We recorded CP duration, BMI, smoking, alcohol consumption and medication. We determined the serum values for A, D and E vitamins, albumin, creatinine, haemoglobin, calcium and magnesium. Bone density measurement was taken from the proximal femur and lumbar spine. CT/MRI scans were used to measure for psoas muscle area. RESULTS A total of 33 patients (median age 62 [39-81] years, 61% male) were included. None of these patients had earlier diagnosis of osteopathy, and none of them had known vitamin deficiency or were sarcopenic. Nineteen patients (57%) had pancreatic exocrine insufficiency and of these seven patients (37%) had no pancreatic enzyme replacement therapy (PERT) and one (5%) had inadequate enzyme therapy. During the study, osteoporosis was diagnosed in 20% and possible sarcopenia in 48% of patients. PEI and inadequate PERT was associated with low E vitamin levels (75% vs. 0%, p = 0.012), higher risk of osteoporosis (43% vs. 5.6%, p = 0.013) and sarcopenia (80% vs. 36%, p = 0.044). CONCLUSION This study demonstrates that chronic pancreatitis is associated with osteoporosis, sarcopenia and vitamin deficiency. If untreated, pancreatic exocrine insufficiency is associated with increased risk of these outcomes. This highlights the importance of identifying and treating PEI in CP patients.
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Affiliation(s)
- Mikael Parhiala
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Elämänaukio, Kuntokatu 2, 33520, Tampere, Finland.
| | - Mika Ukkonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Elämänaukio, Kuntokatu 2, 33520, Tampere, Finland
| | - Juhani Sand
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Johanna Laukkarinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Elämänaukio, Kuntokatu 2, 33520, Tampere, Finland
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2
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Dugic A, Hagström H, Dahlman I, Rutkowski W, Daou D, Kulinski P, Löhr J, Vujasinovic M. Post-pancreatitis diabetes mellitus is common in chronic pancreatitis and is associated with adverse outcomes. United European Gastroenterol J 2022; 11:79-91. [PMID: 36454055 PMCID: PMC9892477 DOI: 10.1002/ueg2.12344] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/20/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Post-pancreatitis diabetes mellitus (PPDM) is a common consequence of chronic pancreatitis (CP). We aimed to determine the incidence and predictors of PPDM after CP onset, as well as complications and antidiabetic therapy requirements, in a high-volume tertiary center. METHODS We did a cohort study with retrospectively collected data from patients with definite CP seen at the Karolinska University Hospital between January 1999 and December 2020. Cause-specific Cox regression analysis was used to assess PPDM predictors. To estimate risk of complications and need for therapy the Fine-Gray subdistribution hazard model was employed, accounting for death as a competing risk. RESULTS We identified 481 patients with CP. The cumulative incidence of PPDM was 5.1%, 13.2%, 27.5% and 38.9% at 5, 10, 15 and 20 years, respectively. Compared to CP patients without diabetes, patients with PPDM were predominantly male (55% vs. 75%), had more frequently alcoholic etiology (44% vs. 62%) and previous acute pancreatitis. The only independent predictor of PPDM was presence of pancreatic calcifications (aHR = 2.45, 95% CI 1.30-4.63). Patients with PPDM had higher rates of microangiopathy (aSHR = 1.59, 95% CI 1.02-2.52) and infection (aSHR = 4.53, 95% CI 2.60-9.09) compared to CP patients who had type 2 diabetes (T2DM). The rate of insulin use was three-fold higher, whereas metformin use rate was two-fold higher in the same comparison. CONCLUSIONS Patients with PPDM have a higher frequency of clinically significant complications and were more commonly prescribed insulin and metformin, suggesting a more aggressive phenotype than that of T2DM. Greater PPDM awareness is needed to optimize disease management.
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Affiliation(s)
- Ana Dugic
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden
| | - Hannes Hagström
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden,Department of Upper Abdominal DiseasesKarolinska University HospitalStockholmSweden,Clinical Epidemiology UnitDepartment of MedicineSolna, Karolinska InstituteStockholmSweden
| | - Ingrid Dahlman
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden
| | - Wiktor Rutkowski
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden
| | - Diana Daou
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden
| | - Paula Kulinski
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden
| | - J.‐Matthias Löhr
- Department of Upper Abdominal DiseasesKarolinska University HospitalStockholmSweden,Department of Clinical Science, Intervention, and Technology (CLINTEC)Karolinska InstituteStockholmSweden
| | - Miroslav Vujasinovic
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden,Department of Upper Abdominal DiseasesKarolinska University HospitalStockholmSweden
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Olesen SS, Viggers R, Drewes AM, Vestergaard P, Jensen MH. Risk of Major Adverse Cardiovascular Events, Severe Hypoglycemia, and All-Cause Mortality in Postpancreatitis Diabetes Mellitus Versus Type 2 Diabetes: A Nationwide Population-Based Cohort Study. Diabetes Care 2022; 45:1326-1334. [PMID: 35312752 DOI: 10.2337/dc21-2531] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/22/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Postpancreatitis diabetes mellitus (PPDM) is a frequent complication of pancreatitis and associates with poor glycemic control. We investigated the risk of adverse diabetes-related outcomes in PPDM compared with type 2 diabetes. RESEARCH DESIGN AND METHODS In this Danish population-based cohort study, we included adults (>18 years) with incident PPDM or type 2 diabetes between 1998 and 2018 through national health registries. PPDM was further divided into acute (PPDM-A) and chronic (PPDM-C) subtypes. We ascertained risk of major adverse cardiovascular events (MACE), severe hypoglycemia, and all-cause mortality as well as incidence rates of severe hypoglycemia. We compared risk and incidence rates across diabetes subgroups using multivariate Cox and Poisson regression analyses. RESULTS We identified 383,325 people with incident type 2 diabetes, 3,418 with PPDM-A, and 2,461 with PPDM-C. Compared with type 2 diabetes, PPDM-C was associated with increased risks of severe hypoglycemia (hazard ratio [HR] 5.27, 95% CI 4.62-6.00, P < 0.001) and all-cause mortality (HR 1.54, 95% CI 1.45-1.64, P < 0.001). Similar patterns were observed for people with PPDM-A. Incidence rate ratios (IRRs) for severe hypoglycemia were increased in both PPDM-C (IRR 7.38, 95% CI 6.75-8.08, P < 0.001) and PPDM-A (IRR 3.76, 95% CI 3.36-4.21, P < 0.001) compared with type 2 diabetes. Findings were consistent in an analysis restricted to people on insulin and in an analysis including pancreatitis patients without diabetes as comparator group. CONCLUSIONS Compared with type 2 diabetes, PPDM is associated with excess risk of adverse diabetes-related outcomes. This has important implications for management.
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Affiliation(s)
- Søren S Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Rikke Viggers
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark.,Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark.,Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Vestergaard
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark.,Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
| | - Morten H Jensen
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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4
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Olesen SS, Svane HML, Nicolaisen SK, Kristensen JK, Drewes AM, Brandslund I, Beck-Nielsen H, Nielsen JS, Thomsen RW. Clinical and biochemical characteristics of postpancreatitis diabetes mellitus: A cross-sectional study from the Danish nationwide DD2 cohort. J Diabetes 2021; 13:960-974. [PMID: 34240829 DOI: 10.1111/1753-0407.13210] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/24/2021] [Accepted: 07/05/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Postpancreatitis diabetes mellitus (PPDM) is a common metabolic sequalae of acute and chronic pancreatitis. We conducted a cross-sectional study to examine the proportion of PPDM among patients clinically diagnosed with type 2 diabetes (T2D) in Denmark and their clinical and biochemical characteristics. METHODS We identified all past diagnoses of pancreatitis among patients in the Danish Centre for Strategic Research in Type 2 Diabetes (DD2) cohort through linkage with national health registries. Using International Classification of Diseases, Tenth Revision codes we categorized patients as PPDM and further divided them into acute/chronic subtypes (PPDM-A and PPDM-C). We assessed PPDM prevalence and examined associations with clinical and biochemical parameters using log binomial or Poisson regression to calculate age-/sex-adjusted prevalence ratios (aPRs). RESULTS Among 5564 patients with a clinical diagnosis of T2D, 78 (1.4%) had PPDM. Compared to T2D, PPDM patients were more often underweight or normal weight (body mass index ≤25.0 kg/m2 : aPR 2.3; 95% confidence interval [CI]: 1.6-3.2) and had lower waist-to-hip ratio (≤0.95/≤0.80 in men/women: aPRs 1.8; 95% CI: 1.2-2.7). PPDM patients had lower plasma amylase levels (<17 U/L: aPRs 2.2; 95% CI: 1.1-4.3), higher insulin sensitivity (homeostatic model assessment 2S [HOMA2S] >63: aPR 2.0; 95% CI: 1.2-3.2) and tended to have worse glycaemic control (HbA1c ≥8.0%: aPRs 1.4; 95% CI: 0.8-2.4). PPDM-A was largely indistinguishable from T2D, whereas PPDM-C had impaired insulin secretion, higher insulin sensitivity, and worse glycemic control. CONCLUSIONS The proportion of PPDM among patients with clinically diagnosed T2D is ~1.5% in an everyday clinical care setting. Glucose metabolism of PPDM-A is largely indistinguishable from T2D, whereas PPDM-C differs in relation to insulin secretion and sensitivity.
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Affiliation(s)
- Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | | | | | | | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Ivan Brandslund
- Department of Biochemistry, Lillebaelt Hospital, Vejle, Denmark
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5
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Therapie des neu aufgetretenen Diabetes mellitus nach einer Pankreatitis. DIABETOLOGE 2021. [DOI: 10.1007/s11428-021-00829-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Diabetes bei chronischer Pankreatitis. DIABETOLOGE 2021. [DOI: 10.1007/s11428-021-00825-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Viggers R, Jensen MH, Laursen HVB, Drewes AM, Vestergaard P, Olesen SS. Glucose-Lowering Therapy in Patients With Postpancreatitis Diabetes Mellitus: A Nationwide Population-Based Cohort Study. Diabetes Care 2021; 44:2045-2052. [PMID: 34362812 DOI: 10.2337/dc21-0333] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Postpancreatitis diabetes mellitus (PPDM) is a type of secondary diabetes that requires special considerations for management. The main objective was to examine prescription patterns of glucose-lowering therapy among adults with PPDM compared with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS In a Danish nationwide population-based cohort study, we identified all individuals with adult-onset diabetes in the period 2000-2018 and categorized them as having type 1 diabetes, type 2 diabetes, or PPDM. We ascertained diabetes incidence rates, clinical and demographic characteristics, and classifications and prescription patterns of glucose-lowering therapy and compared these parameters across diabetes subgroups. RESULTS Among 398,456 adults with new-onset diabetes, 5,879 (1.5%) had PPDM, 9,252 (2.3%) type 1 diabetes, and the remaining type 2 diabetes (96.2%). The incidence rate of PPDM was 7.9 (95% CI 7.7-8.1) per 100,000 person-years versus 12.5 (95% CI 12.2-12.7) for type 1 diabetes (incidence rate ratio 0.6 [95% CI 0.6-0.7]; P < 0.001). A sizeable proportion of patients with PPDM were classified as having type 2 diabetes (44.9%) and prescribed sulfonylureas (25.2%) and incretin-based therapies (18.0%) that can potentially be harmful in PPDM. In contrast, 35.0% of patients never received biguanides, which are associated with a survival benefit in PPDM. Increased insulin requirements were observed for patients with PPDM compared with type 2 diabetes (hazard ratio 3.10 [95% CI 2.96-3.23]; P < 0.001) in particular for PPDM associated with chronic pancreatitis (hazard ratio 4.30 [95% CI 4.01-4.56]; P < 0.001). CONCLUSIONS PPDM is a common type of secondary diabetes in adults but is often misclassified and treated as type 2 diabetes, although PPDM requires special considerations for management.
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Affiliation(s)
- Rikke Viggers
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark .,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Morten Hasselstrøm Jensen
- Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Henrik Vitus Bering Laursen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Peter Vestergaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Gastroenterology and Hepatology, Mech-Sense and Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
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9
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Olesen SS, Hagn-Meincke R, Drewes AM, Steinkohl E, Frøkjaer JB. Pancreatic atrophy and exocrine insufficiency associate with the presence of diabetes in chronic pancreatitis patients, but additional mediators are operative. Scand J Gastroenterol 2021; 56:321-328. [PMID: 33369483 DOI: 10.1080/00365521.2020.1867891] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Diabetes mellitus is a frequent complication of chronic pancreatitis (CP) and has traditionally been considered to develop as a consequence of pancreatic islet cell loss. However, additional mechanisms may be operative including accumulation of pancreatic fat and fibrosis. We used advanced magnetic resonance imaging (MRI) to study pancreatic morphology and exocrine function in a reference population and in CP patients with and without diabetes. METHODS This was a cross-sectional mono centre study. All subjects underwent advanced MRI including assessment of pancreatic ductal parameters (Cambridge classification and main pancreatic duct diameter), parenchymal parameters (DIXON technique and diffusion weighted imaging as proxies for pancreatic fat content and fibrosis, as well as pancreatic volume segmentation). Pancreatic exocrine function was determined as duodenal secretion following secretin stimulation and by the faecal elastase test. RESULTS The study included 76 patients with definite CP of whom 23 (30.1%) had diabetes and 23 sex- and age matched healthy volunteers. Compared to their non-diabetic counterparts, diabetic patients were characterised by a low pancreatic volume (20 vs. 36 ml; p = .02) and impaired pancreatic exocrine function (faecal elastase 19 vs. 48 µg/g; p = .008), while no difference between patients with and without diabetes were seen in relation to MRI derived proxies for fibrosis and pancreatic fat accumulation and pancreatic duct parameters. A large proportion of non-diabetic patients (49%) had similar morphological and functional characteristics as patients with diabetes. CONCLUSION Pancreatic atrophy and exocrine insufficiency are present in most CP patients with diabetes, but additional mediators seem to be operative in post pancreatitis diabetes mellitus.
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Affiliation(s)
- Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Rasmus Hagn-Meincke
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Emilie Steinkohl
- Clinical Institute, Aalborg University, Aalborg, Denmark.,Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjaer
- Clinical Institute, Aalborg University, Aalborg, Denmark.,Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
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Liu Y, Chen HL, Li ZS, Wang D, Hu LH. Letter to the Editor: "Effect of Chronic Pancreatitis on Complications and Mortality in DM Patients: A 10-Year Nationwide Cohort Study". J Clin Endocrinol Metab 2020; 105:5851406. [PMID: 32497218 DOI: 10.1210/clinem/dgaa305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/22/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Yu Liu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Hua-Liang Chen
- School of Basic Medical Sciences, The Second Military Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Dan Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
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