Management
In patients with diabetes secondary to pancreatic disorders, insulin production is usually reduced; as a result, exogenous insulin is often required earlier than for patients with type 2 diabetes.
As well as insulin deficiency, hepatic insulin resistance can be present. The pancreatic alpha cells, which produce glucagon, are affected resulting in an increased risk of both treatment-related and spontaneous hypoglycaemia.
The treatment of diabetes secondary to pancreatic disorders differs from treatment of type 2 diabetes; some classes of antihyperglycaemic drugs should be avoided:
- sulfonylureas increase risk of hypoglycaemia
- dipeptidyl peptidase-4 (DPP-4) inhibitors may be associated with an increased risk of pancreatitis
- glucagon-like peptide-1 (GLP-1) receptor agonists may be associated with an increased risk of pancreatitis
- sodium-glucose co-transporter 2 (SGLT2) inhibitors may increase risk of diabetic ketoacidosis if the patient is insulin deficient
- acarbose can aggravate existing exocrine insufficiency
- thiazolidinediones are associated with some adverse effects that are additive to complications of pancreatic exocrine dysfunction (eg bone fractures).
Evidence to guide management of diabetes secondary to pancreatic disorders is lacking. Treatment must be individualised. As for type 2 diabetes, metformin is first-line treatment in the absence of contraindications (eg excess alcohol use and/or risk of lactic acidosis). With disease progression and more severe hyperglycaemia, insulin treatment is usually needed.
Associated pancreatic exocrine insufficiency must also be managed, see Pancreatic exocrine insufficiency for information on management.