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Edited and written by Yimaitong, please do not reprint without authorization.
Introduction: Type 3C diabetes is most often misdiagnosed as type 2 diabetes (T2DM), but it requires more attention to details than T2DM in terms of treatment.
How is this type of diabetes diagnosed? What are the special features of the selection and use of hypoglycemic drugs? What is type 3C diabetes? Type 3C diabetes is the representative name of pancreatic diabetes.
An expert consensus issued by the American Diabetes Association (ADA) in 2014 listed four major types of diabetes, among which pancreatic diabetes is ranked III C, hence the name.
Its main feature is that both the pancreatic endocrine and exocrine glands are damaged.
The glucose metabolism disorder ranges from mild damage to the severe form characterized by frequent hypoglycemia, namely fragile diabetes.
The clinical heterogeneity is large, and there are certain challenges in diagnosis and treatment.
Type 3C diabetes is not uncommon.
At present, there are few survey data related to the prevalence of type 3C diabetes in China, and there are large differences in the results of related flows in the world.
Early on, the prevalence was considered to be very low and only 1%.
However, follow-up reports in the literature have reported that the prevalence of type 3C diabetes is as high as 15%-20% in Southeast Asia where tropical or fibrocalcifying pancreatitis is endemic; 2016 Lancet Gastroenterol A study published by Hepatol showed that type 3C diabetes accounts for about 1%-9% of all diabetic patients.
It is particularly important to note that in patients with hereditary pancreatitis, the incidence of type 3C diabetes can be as high as 80%.
What is the difference between type 3C diabetes and traditional type 1 and type 2 diabetes? A large sample study from Germany showed that: ➤Compared with T1DM, Type 3C diabetes has a relatively low level of glycosylated hemoglobin (HbA1c) and the incidence of microvascular complications, but its severe hypoglycemia, hypoglycemic coma, and macrovascular disease occur.
The rate is significantly higher than that of T1DM; ➤Compared with T2DM, the incidence of macrovascular and microvascular complications of type 3C diabetes is relatively low, but the incidence of insulin dosage, HbA1c level, severe hypoglycemia and hypoglycemic coma is significant Higher than T2DM.
How is type 3C diabetes diagnosed? There is no consensus on the diagnostic criteria of type 3C diabetes at home and abroad.
At present, the more recognized diagnostic criteria is based on "blood sugar meets the diagnostic criteria of diabetes" plus: Main criteria (must meet): 1.
Exocrine pancreatic insufficiency (through single Cloned fecal elastase-1 detection); 2.
There are pancreatic pathological changes (pancreatic endoscopic ultrasound, magnetic resonance imaging, CT findings are abnormal); 3.
There is no autoimmune antibody related to type 1 diabetes (T1DM).
Secondary criteria: 1.
Pancreatic β-cell function is impaired; 2.
No obvious insulin resistance [such as homeostatic model insulin resistance index (HOMA-IR) test]; 3.
The presence of incretin [glucagon-like peptide 1 (GLP‑1) etc.
] Impaired secretion; 4.
Decreased blood fat-soluble vitamin concentration; 5.
Accompanied by steatorrhea that can be corrected by pancreatin.
In clinical work, the diagnosis can be confirmed by meeting the main diagnostic criteria.
For those with secondary criteria, it is recommended to conduct inspections of the main diagnostic criteria, or make a preliminary diagnosis and conduct experimental treatment.
Disease treatment-management/prevention of malnutrition is the primary goal The primary goal of treatment for type 3C diabetes is to prevent or treat malnutrition, control steatorrhea, and minimize high blood sugar caused by eating.
Oral pancreatin supplementation can increase fat absorption, reduce steatorrhea, and increase the absorption of fat-soluble vitamins.
It can also increase the stimulation of intestinal amino acids, fatty acids and other substances on incretin, increase the release of postprandial insulin, and reduce postprandial blood sugar.
In addition, vitamin D should be used throughout to prevent osteoporotic bone disease.
Disease treatment—the selection and precautions of hypoglycemic drugs There is currently no specific drug recommendation guidelines, which can be selected according to the characteristics of patients and the degree of insulin deficiency.
However, due to the complexity of the disease, there are many problems that need to be paid attention to in clinical use .
1.
After insulin pancreatic inflammation, β-cell dysfunction or complete loss, coupled with intestinal digestion and absorption disorders and decreased secretion of incretin, reduce the body's sensitivity to hyperglycemia, making oral hypoglycemic drugs difficult to control blood sugar in type 3C diabetes Level, leading to earlier timing of insulin activation.
Due to the possibility of increased peripheral insulin sensitivity and glucagon deficiency, patients with pancreatic diabetes need a lower insulin dose, and the risk of ketoacidosis is lower, but hypoglycemia is more likely to occur and recover from hypoglycemia It is slower, therefore, extra care should be taken to avoid hypoglycemia during insulin treatment.
The following data can be used as a reference for patients with type 3C diabetes: a systematic review shows that after acute pancreatitis, about 15% of patients need insulin therapy.
After 5 years of follow-up, 108 diabetic patients with severe pancreatitis use insulin.
The insulin ratio is 25%.
Compared with acute pancreatitis, after chronic pancreatitis, patients start insulin earlier and the proportion is also higher.
According to literature, the insulin usage rate within 5 years after acute pancreatitis is about 20%, and that of diabetes after chronic pancreatic disease is 45.
8%, which is significantly higher, and the T2DM control group is only 4.
1%.
2.
Metformin can be used as a first-line drug in the early stage of diabetes when blood sugar is only slightly elevated or accompanied by obvious insulin resistance, and can be applied to the entire treatment, but once weight loss, steatorrhea and other symptoms of pancreatic exocrine insufficiency occur, it is necessary Use with caution to avoid further aggravating gastrointestinal symptoms.
3.
Sulfonylureas and Glinides.
Sulfonylureas and Glinides are insulin secretagogues, which have a higher risk of hypoglycemia and should be carefully selected.
Short-acting Glinides can be taken before meals when meals are irregular.
.
4.
Thiazolidinediones Patients with pancreatic exocrine dysfunction are prone to osteoporosis, while thiazolidinediones may increase the risk of fractures and should be used with caution. 5.
Glucagon-like peptide-1 receptor agonist (GLP-1RA) and dipeptidyl peptidase 4 inhibitor (DPP-4i) GLP-1RA and DPP-4i belong to the secretin drugs, these drugs Although it can promote insulin secretion, GLP-1RA has obvious gastrointestinal side effects, and it is still controversial whether the two increase the risk of pancreatitis and pancreatic cancer.
Such drugs are not recommended for patients with type 3C diabetes, or they need to be used with caution.
6.
Sodium-glucose cotransporter 2 inhibitor (SGLT-2i) Due to its unique mechanism of action, SGLT-2i can increase urinary glucose excretion, but at the same time it may cause the loss of nutrients, which will aggravate malnutrition.
Summary Type 3C diabetes is a synonym for pancreatic diabetes.
It is a special type of diabetes secondary to pancreatic exocrine disease.
It is not uncommon in clinical practice.
It is very easy to be missed and misdiagnosed in clinical practice.
It needs attention.
Due to the simultaneous existence of pancreatic endocrine and exocrine dysfunction and a variety of hormone abnormalities, the pathophysiological mechanism of pancreatic diabetes is complicated, and the clinical manifestations are heterogeneous.
Diagnosis and treatment are both difficult to diagnose.
In the future, more research is needed to develop more effective Diagnostic criteria and treatment plan. References: [1] Zhou Yan, Cao Hongwei, Ji Qiuhe.
Type 3C diabetes is also an important type of diabetes[J].
Chinese Journal of Internal Medicine, 2021, 60(1): 9-12.
DOI: 10.
3760/cma .
j.
cn112138-20201110-00932.
[2] Yu Jie, Zhang Huabing, Li Yuxiu.
Pancreatic diabetes[J].
Chinese Journal of Diabetes, 2021,13 (01): 116-118.
DOI: 10.
3760/cma.
j.
cn115791-20201105-00656[3]American Diabetes Association.
Diagnosis and classification of diabetes mellitus[J].
Diabetes Care, 2013, 36Suppl 1:S67-74.
[4]American Diabetes Association.
Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021.
Diabetes Care 2021;44 (Suppl.
1):S15-S33
Introduction: Type 3C diabetes is most often misdiagnosed as type 2 diabetes (T2DM), but it requires more attention to details than T2DM in terms of treatment.
How is this type of diabetes diagnosed? What are the special features of the selection and use of hypoglycemic drugs? What is type 3C diabetes? Type 3C diabetes is the representative name of pancreatic diabetes.
An expert consensus issued by the American Diabetes Association (ADA) in 2014 listed four major types of diabetes, among which pancreatic diabetes is ranked III C, hence the name.
Its main feature is that both the pancreatic endocrine and exocrine glands are damaged.
The glucose metabolism disorder ranges from mild damage to the severe form characterized by frequent hypoglycemia, namely fragile diabetes.
The clinical heterogeneity is large, and there are certain challenges in diagnosis and treatment.
Type 3C diabetes is not uncommon.
At present, there are few survey data related to the prevalence of type 3C diabetes in China, and there are large differences in the results of related flows in the world.
Early on, the prevalence was considered to be very low and only 1%.
However, follow-up reports in the literature have reported that the prevalence of type 3C diabetes is as high as 15%-20% in Southeast Asia where tropical or fibrocalcifying pancreatitis is endemic; 2016 Lancet Gastroenterol A study published by Hepatol showed that type 3C diabetes accounts for about 1%-9% of all diabetic patients.
It is particularly important to note that in patients with hereditary pancreatitis, the incidence of type 3C diabetes can be as high as 80%.
What is the difference between type 3C diabetes and traditional type 1 and type 2 diabetes? A large sample study from Germany showed that: ➤Compared with T1DM, Type 3C diabetes has a relatively low level of glycosylated hemoglobin (HbA1c) and the incidence of microvascular complications, but its severe hypoglycemia, hypoglycemic coma, and macrovascular disease occur.
The rate is significantly higher than that of T1DM; ➤Compared with T2DM, the incidence of macrovascular and microvascular complications of type 3C diabetes is relatively low, but the incidence of insulin dosage, HbA1c level, severe hypoglycemia and hypoglycemic coma is significant Higher than T2DM.
How is type 3C diabetes diagnosed? There is no consensus on the diagnostic criteria of type 3C diabetes at home and abroad.
At present, the more recognized diagnostic criteria is based on "blood sugar meets the diagnostic criteria of diabetes" plus: Main criteria (must meet): 1.
Exocrine pancreatic insufficiency (through single Cloned fecal elastase-1 detection); 2.
There are pancreatic pathological changes (pancreatic endoscopic ultrasound, magnetic resonance imaging, CT findings are abnormal); 3.
There is no autoimmune antibody related to type 1 diabetes (T1DM).
Secondary criteria: 1.
Pancreatic β-cell function is impaired; 2.
No obvious insulin resistance [such as homeostatic model insulin resistance index (HOMA-IR) test]; 3.
The presence of incretin [glucagon-like peptide 1 (GLP‑1) etc.
] Impaired secretion; 4.
Decreased blood fat-soluble vitamin concentration; 5.
Accompanied by steatorrhea that can be corrected by pancreatin.
In clinical work, the diagnosis can be confirmed by meeting the main diagnostic criteria.
For those with secondary criteria, it is recommended to conduct inspections of the main diagnostic criteria, or make a preliminary diagnosis and conduct experimental treatment.
Disease treatment-management/prevention of malnutrition is the primary goal The primary goal of treatment for type 3C diabetes is to prevent or treat malnutrition, control steatorrhea, and minimize high blood sugar caused by eating.
Oral pancreatin supplementation can increase fat absorption, reduce steatorrhea, and increase the absorption of fat-soluble vitamins.
It can also increase the stimulation of intestinal amino acids, fatty acids and other substances on incretin, increase the release of postprandial insulin, and reduce postprandial blood sugar.
In addition, vitamin D should be used throughout to prevent osteoporotic bone disease.
Disease treatment—the selection and precautions of hypoglycemic drugs There is currently no specific drug recommendation guidelines, which can be selected according to the characteristics of patients and the degree of insulin deficiency.
However, due to the complexity of the disease, there are many problems that need to be paid attention to in clinical use .
1.
After insulin pancreatic inflammation, β-cell dysfunction or complete loss, coupled with intestinal digestion and absorption disorders and decreased secretion of incretin, reduce the body's sensitivity to hyperglycemia, making oral hypoglycemic drugs difficult to control blood sugar in type 3C diabetes Level, leading to earlier timing of insulin activation.
Due to the possibility of increased peripheral insulin sensitivity and glucagon deficiency, patients with pancreatic diabetes need a lower insulin dose, and the risk of ketoacidosis is lower, but hypoglycemia is more likely to occur and recover from hypoglycemia It is slower, therefore, extra care should be taken to avoid hypoglycemia during insulin treatment.
The following data can be used as a reference for patients with type 3C diabetes: a systematic review shows that after acute pancreatitis, about 15% of patients need insulin therapy.
After 5 years of follow-up, 108 diabetic patients with severe pancreatitis use insulin.
The insulin ratio is 25%.
Compared with acute pancreatitis, after chronic pancreatitis, patients start insulin earlier and the proportion is also higher.
According to literature, the insulin usage rate within 5 years after acute pancreatitis is about 20%, and that of diabetes after chronic pancreatic disease is 45.
8%, which is significantly higher, and the T2DM control group is only 4.
1%.
2.
Metformin can be used as a first-line drug in the early stage of diabetes when blood sugar is only slightly elevated or accompanied by obvious insulin resistance, and can be applied to the entire treatment, but once weight loss, steatorrhea and other symptoms of pancreatic exocrine insufficiency occur, it is necessary Use with caution to avoid further aggravating gastrointestinal symptoms.
3.
Sulfonylureas and Glinides.
Sulfonylureas and Glinides are insulin secretagogues, which have a higher risk of hypoglycemia and should be carefully selected.
Short-acting Glinides can be taken before meals when meals are irregular.
.
4.
Thiazolidinediones Patients with pancreatic exocrine dysfunction are prone to osteoporosis, while thiazolidinediones may increase the risk of fractures and should be used with caution. 5.
Glucagon-like peptide-1 receptor agonist (GLP-1RA) and dipeptidyl peptidase 4 inhibitor (DPP-4i) GLP-1RA and DPP-4i belong to the secretin drugs, these drugs Although it can promote insulin secretion, GLP-1RA has obvious gastrointestinal side effects, and it is still controversial whether the two increase the risk of pancreatitis and pancreatic cancer.
Such drugs are not recommended for patients with type 3C diabetes, or they need to be used with caution.
6.
Sodium-glucose cotransporter 2 inhibitor (SGLT-2i) Due to its unique mechanism of action, SGLT-2i can increase urinary glucose excretion, but at the same time it may cause the loss of nutrients, which will aggravate malnutrition.
Summary Type 3C diabetes is a synonym for pancreatic diabetes.
It is a special type of diabetes secondary to pancreatic exocrine disease.
It is not uncommon in clinical practice.
It is very easy to be missed and misdiagnosed in clinical practice.
It needs attention.
Due to the simultaneous existence of pancreatic endocrine and exocrine dysfunction and a variety of hormone abnormalities, the pathophysiological mechanism of pancreatic diabetes is complicated, and the clinical manifestations are heterogeneous.
Diagnosis and treatment are both difficult to diagnose.
In the future, more research is needed to develop more effective Diagnostic criteria and treatment plan. References: [1] Zhou Yan, Cao Hongwei, Ji Qiuhe.
Type 3C diabetes is also an important type of diabetes[J].
Chinese Journal of Internal Medicine, 2021, 60(1): 9-12.
DOI: 10.
3760/cma .
j.
cn112138-20201110-00932.
[2] Yu Jie, Zhang Huabing, Li Yuxiu.
Pancreatic diabetes[J].
Chinese Journal of Diabetes, 2021,13 (01): 116-118.
DOI: 10.
3760/cma.
j.
cn115791-20201105-00656[3]American Diabetes Association.
Diagnosis and classification of diabetes mellitus[J].
Diabetes Care, 2013, 36Suppl 1:S67-74.
[4]American Diabetes Association.
Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021.
Diabetes Care 2021;44 (Suppl.
1):S15-S33
