Elsevier

Pancreatology

Volume 13, Issue 4, July–August 2013, Pages 336-342
Pancreatology

Original article
Detection, evaluation and treatment of diabetes mellitus in chronic pancreatitis: Recommendations from PancreasFest 2012

https://doi.org/10.1016/j.pan.2013.05.002Get rights and content

Abstract

Description

Diabetes and glucose intolerance are common complications of chronic pancreatitis, yet clinical guidance on their detection, classification, and management is lacking.

Methods

A working group reviewed the medical problems, diagnostic methods, and treatment options for chronic pancreatitis-associated diabetes for a consensus meeting at PancreasFest 2012.

Results

Guidance Statement 1.1: Diabetes mellitus is common in chronic pancreatitis. While any patient with chronic pancreatitis should be monitored for development of diabetes, those with long-standing duration of disease, prior partial pancreatectomy, and early onset of calcific disease may be at higher risk. Those patients developing diabetes mellitus are likely to have co-existing pancreatic exocrine insufficiency.

Guidance Statement 1.2: Diabetes occurring secondary to chronic pancreatitis should be recognized as pancreatogenic diabetes (type 3c diabetes).

Guidance Statement 2.1: The initial evaluation should include fasting glucose and HbA1c. These tests should be repeated annually. Impairment in either fasting glucose or HbA1c requires further evaluation.

Guidance Statement 2.2: Impairment in either fasting glucose or HbA1c should be further evaluated by a standard 75 g oral glucose tolerance test.

Guidance Statement 2.3: An absent pancreatic polypeptide response to mixed-nutrient ingestion is a specific indicator of type 3c diabetes.

Guidance Statement 2.4: Assessment of pancreatic endocrine reserve, and importantly that of functional beta-cell mass, should be performed as part of the evaluation and follow-up for total pancreatectomy with islet autotransplantation (TPIAT).

Guidance Statement 3: Patients with pancreatic diabetes shall be treated with specifically tailored medical nutrition and pharmacologic therapies.

Conclusions

Physicians should evaluate and treat glucose intolerance in patients with pancreatitis.

Section snippets

Rationale

Chronic pancreatitis is a syndrome of pancreatic inflammation with irreversible parenchymal damage and functional changes that is complicated by progressive nutrient maldigestion, glucose intolerance, diabetes mellitus, and metabolic derangements. The complex timing and interactions between nutrient digestion, absorption, and utilization that are normally regulated by the pancreas are variably disrupted with inflammatory and fibrotic injury. Failure to digest nutrients in the proximal gut may

Guideline focus

The PancreasFest working group framed the development of their discussion questions and guidance statements around three areas of concern: 1) the pathophysiology of diabetes mellitus occurring in the setting of chronic pancreatitis; 2) the distinction of pancreatogenic (type 3c) from type 1 and type 2 diabetes; and 3) the evaluation and management of pancreatogenic diabetes in the context of current endocrine practice.

Target population

The clinical recommendations guide the evaluation and management of diabetes mellitus and glucose intolerance in adult patients with recurrent acute and chronic pancreatitis.

Guideline development process

PancreasFest is an annual meeting that brings together physicians and scientists with interests in the pancreas: pancreatologists, endoscopists, surgeons, radiologists, molecular biologists, geneticists, endocrinologists, epidemiologists, statisticians, systems biologists, and experts in biomarkers (typically 150+ attendees).

At PancreasFest 2009, an expert working group convened to identify the most important clinical questions related to diabetes mellitus in chronic pancreatitis and prepared

Evidence review and grading

Methods of developing consensus were based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Grid to reach decisions on clinical practice guidelines [8] and the Surviving Sepsis Campaign report [9].

Evidence and modification

The discussion questions presented to attendees of PancreasFest 2012 were followed by one or more guidance statements intended to provide a concise summary and, if indicated, a clinical recommendation. Conference attendees discussed the initial questions and guidance statements of the working group, which were projected for the entire conference to see and revise in real-time. The conference participants then voted on the level of agreement with the statements, with the results tabulated and

Discussion Question 1.1: In chronic pancreatitis, are there specific risk factors for developing diabetes mellitus?

Guidance Statement 1.1: Diabetes mellitus is common in chronic pancreatitis. While any patient with chronic pancreatitis should be monitored for development of diabetes, those with long-standing duration of disease, prior partial pancreatectomy, and early onset of calcific disease may be at higher risk. Those patients developing diabetes mellitus are likely to have co-existing pancreatic exocrine insufficiency.

Level of Agreement: A 58%; B 42%; C 0%; D 0%; E 0%

Evidence: Diabetes mellitus has

Research recommendations

The systematic review of glucose intolerance and diabetes mellitus in the setting of pancreatitis revealed knowledge gaps in definition and detection (Guidance Statements 1.1–1.2), diagnosis (Guidance Statements 2.1–2.4), and treatment (Guidance Statement 3). Further research in the following specific areas was recommended to provide stronger levels of evidence in areas of uncertainty or lower levels of agreement.

Guidance Statement 1.1: Further refinement of risk stratification is needed for

Summary

These statements represent the most current, clinically relevant recommendations on the evaluation and treatment of glucose intolerance and diabetes mellitus in patients with recurrent acute and chronic pancreatitis. Type 3c pancreatitis may also occur with other disorders such as hemochromatosis and pancreatic cancer, which were not addressed by the working group. There was strong consensus (≥90% agreement, as indicated by A or B in Table 1) that a large portion of patients with chronic

Disclosure statement

The authors have no relevant conflicts of interest related to this material.

Author contributions

Developed the concept and the consensus process: M.A.A., R.E.B, L.F. and D.C.W.

Diabetes Working Group: M.R.R. (chair), D.K.A., M.B., S.C., F.G.S.T. and R.P.R.

Wrote the Manuscript: M.R.R. and D.C.W.

Participated in discussion of statements, reviewed and approved manuscript: All authors and participants.

Acknowledgments

This work was supported in part by conference grants from the National Institute of Diabetes and Digestive and Kidney Diseases [R13DK083216 (2009), R13DK088452 (2010), and R13DK09604 (2012)] and accredited physician education supported by Abbott Laboratories, Aptalis Pharma, Boston Scientific, Cook Medical, Lilly, and Olympus through the University of Pittsburgh office of Continuing Medical Education. The authors thank Ms. Michelle Kienholz, Ms. Joy Jenko Merusi, and Ms. Marianne Davis for

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    Authors are the working group members; a complete list of participants who discussed the statements, voted, reviewed and approved the document are given in the Appendix.

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