The background: a 48 year old gentleman with a 4 year history of being on treatment for type 2 diabetes. He had recurrent episodes of pancreatitis brought about by excessive alcohol intake. He had been abstinent for almost 3 years. He had visited for exacerbation of sugar levels with random low sugar levels and was associated with frequent loose bowel movements. He is physically active and has been following up with his ophthalmologist for the blurred vision.
Clinically blood pressure was normal, BMI was 22. Clinical parameters included a glycated hemoglobin of 10% with normal lipid and kidney parameters. He has been compliant with his medicines which included metformin 1 g twice a day, empagliflozin 25 mg once a day and sitagliptin 100 mg once daily for diabetes management.
An upper and lower GI endoscopy did not reveal any pathology.
What options going forward?
- Change metformin immediate release form to an extended release form to help his bowel movement?
- Add another class of oral medicines?
- Add a GLP1RA agent?
- Will you investigate by performing the C peptide level, autoantibodies to determine if type 1 or LADA?
Because of the history of recurrent alcohol induced pancreatitis, it is best to perform a fecal elastase 1 level ( to test the exocrine function of pancreas) , besides doing a CT or MRI of the pancreas. C peptide , autoantibody titers are also done for excluding either Type 1 diabetes or LADA.
Discussion: The patients are generally underweight, often associated with severe hypoglycemia, low insulin and glucagon levels. The stool is greasy and frothy, foul smelling often associated with weight loss, abdominal distension and flatulence. The fecal elastase levels are low and the treatment plans will include removing incretin based therapy, adding insulin to the treatment with close monitoring of the sugar levels using a continuous glucose monitoring device and vitamin D supplementation to reduce the risk of osteoporosis or osteopenia. The peripheral insulin sensitivity is increased. The risk to develop pancreatic cancer is high.
The endocrine part of pancreas is responsible for the secretion of insulin from the beta cells and glucagon from the alpha cells. The exocrine part of pancreas secretes amylase, lipase and proteases.
