Q J Med 2010; 103:759–763 doi:10.1093/qjmed/hcq127 Advance Access Publication 22 July 2010

Diabetes due to exocrine pancreatic disease—a review of patients attending a hospital-based diabetes clinic S. PRICE1, D. COLE2 and J.C. ALCOLADO3 From the 1Department of Medicine, 2Department of Medical Biochemistry & Immunology, Cardiff University School of Medicine, Heath Park, Cardiff, Wales, UK and 3Barts and The London School of Medicine, Queen Mary, University of London, Whitechapel, London, UK Address correspondence to Prof. J.C. Alcolado, Medical Education Centre, Queens Hospital, Rom Valley Way Romford, Essex, RM7 0AG, UK. email: [email protected] Received 26 March 2010 and in revised form 14 June 2010

Summary Background: Diabetes secondary to underlying exocrine pancreatic disease is a specific, but heterogeneous, type of diabetes mellitus. Studies such as UKPDS and DCTT excluded patients with pancreatic diabetes, so there is a paucity of evidence regarding best clinical practice in this group. Aim: To characterize the clinical features of patients with diabetes secondary to underlying pancreatic disease attending general diabetes clinics in a single hospital. Design and Methods: A cross-sectional observational cohort study, identifying patients with pancreatic diabetes from clinic letters and medical notes at the University Hospital of Wales, Cardiff, UK. Results: The notes of 38 patients with pancreatic diabetes were reviewed. Of these, six had pancreatic malignancy and the remainder had a range of benign disorders. The majority (29/38) had diabetes

Introduction Diabetes due to underlying exocrine pancreatic disease is a specific sub-type in the World Health Organization classification of diabetes mellitus.1 It includes conditions such as pancreatitis (acute, relapsing or chronic), trauma, pancreactomy and cystic fibrosis. However, a degree of overlap exists since long-standing Types 1 and 2 diabetes are associated with some degree of exocrine pancreatic

diagnosed at or shortly after the pancreatic diagnosis was made. There was a lack of consistency regarding initial hypoglycaemic therapy, with metformin alone being the most common initial therapy, but with 30/38 taking insulin within 12 months of diagnosis. Similarly, a broad range of insulin regimens were employed with twice daily pre-mixed insulin being most prevalent. Sixty-three percent of patients were prescribed lipid lowering therapy and 42% were taking anti-hypertensives. Glycaemic control, as estimated by the latest HbA1C, was no different in patients with pancreatic diabetes compared to the general clinic population and there were no reports of severe hypoglycaemia. Conclusions: There is great variability in how patients with pancreatic diabetes are currently managed. Future clinical trials should specifically address this group.

failure,2 and people with diabetes are also at least as likely as the general population to develop acute pancreatitis.3,4 Similarly, patients with previous episodes of pancreatitis may develop Type 1 or 2 diabetes independently of their past pancreatic insults. Furthermore, pancreatic cancer, and hence the need for pancreatic resection, is known to be more common in people with pre-existing diabetes.5,6

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Given this overlap of classification sub-types, and a lack of consistency regarding the clinical diagnosis of pancreatitis, the true prevalence of significant exocrine pancreatic failure in patients with diabetes is unknown. In studies where faecal elastase has been measured as a surrogate marker of pancreatic function, as many as 22% of patients in general diabetes clinics have a severely reduced level (