Diabetes Patients with Diabetes Stemming from Pancreatitis or Pancreas-Removal Surgery Have Special Risks Patients who develop diabetes as a result of chronic pancreatitis or following surgery to remove their pancreas have risks and treatment indications that are significantly different from others who are diagnosed with diabetes as adults. While approximately 95 percent of diabetes patients have insulin-resistant type 2, “diabetes related to pancreatic disease is a process that is much more like type 1 diabetes — and even then there are important distinctions,” says endocrinologist Matthew Freeby, MD, director of the Gonda Diabetes Center and associate director of UCLA diabetes clinical programs. He notes, for example, that patients with diabetes resulting from chronic pancreatitis or pancreatic surgery tend to be more susceptible to experiencing complications such as loss of consciousness and seizures from hypoglycemia. “These patients are in an insulin-deficient state and typically lacking glucagon, an important hormone reducing hypoglycemia risk,” Dr. Freeby says. They “require intensive diabetes education and treatment by a team that is knowledgeable in the use of continuous- glucose-monitoring devices and how best to deliver insulin therapy through multiple daily injections or, potentially, using insulin pumps,” Dr. Freeby says. Nearly half of patients with chronic pancreatitis progress to diabetes. “It’s believed that about 1-to-2 percent of the healthy pancreas is made up of beta cells that produce insulin, and these are being destroyed over time by the disease,” Dr. Freeby explains. For these insulin-deficient patients, keeping sugars under control is especially important and can be challenging. Not only are these patients prone to hyperglycemia and its immediate impact, but they also are at risk for chronic complications. The same is true for patients who, as a result of a pancreatectomy, lose the ability to produce insulin, leading to a condition referred to as “brittle diabetes.” One reason these patients are at a particularly high risk for low blood sugars is that they also have lost their glucagon-secreting alpha cells, which play a key regulatory role in keeping sugars sufficiently high. As a result, Dr. Freeby says, insulin must be given to these patients in lower doses to reduce the risk for hypoglycemia. Additionally, in the period following the pancreatectomy, when a patient is experiencing significant inflammation throughout his or her body, the insulin requirements are likely to be different from what they will be further along in their recovery, Dr. Freeby adds. Thus, it is crucial to closely monitor patients to determine their insulin requirements as the inflammation is reduced and activity levels increase. “For patients who are having pancreatic removal, it’s especially important to provide a strong education component both before and after the surgery,” Dr. Freeby says. Prior to the operation, the UCLA team explains what it will mean for the patient to develop diabetes, including the importance of blood- sugar control and how to monitor it, as well as how to administer insulin and in what doses. Following surgery, these patients are managed by a team that includes an endocrinologist, nutritionist and diabetes nurse who continue to provide education, as well as working with patients on the nuances of adjusting both long-acting and short-acting insulin. “For patients who are having pancreatic removal, it’s especially important to provide a strong education component both before and after the surgery.” “It’s very important to recognize that, even though these patients with pancreatic diseases are being diagnosed with diabetes as adults, this is not type 2 diabetes,” Dr. Freeby says. “With patients who have type 2 diabetes, we think about oral medications as first-line therapy, but those aren’t going to work for someone with diabetes related to chronic pancreatitis or surgical removal of the pancreas. For these patients, it isn’t about making the insulin work better; it’s about getting that insulin back.” 3 UCLA Physicians Update