DIABETES MELLITUS AND EXOCRINE PANCREATIC INSUFFICIENCY: A CONTEMPORARY PERSPECTIVE ON THE PROBLEM

Abstract

Exocrine pancreatic insufficiency (EPI) is increasingly recognized as a common comorbidity in both type 1 and type 2 diabetes mellitus (DM), which remains largely underdiagnosed due to nonspecific clinical manifestations and the lack of standardized screening protocols. The aim of this article is to summarize current evidence regarding the pathophysiological mechanisms, epidemiology, clinical features, diagnostic algorithms, and treatment strategies for EPI in patients with DM.

A literature search was conducted using the databases Web of Science, Scopus, The Cochrane Library, MedLine, EMBASE, Global Health, etc.

The paper highlights the close functional interdependence between the endocrine and exocrine compartments of the pancreas, in which dysfunction of one component often leads to impairment of the other. It is shown that the development of EPI is driven by insulin deficiency (especially in type 1 DM), insulin resistance (type 2 DM), oxidative and endoplasmic stress, autoimmune inflammation, microangiopathy, and the influence of certain nutrients (fructose, ethanol, BCAAs). The clinical relevance of EPI is substantiated in the context of impaired nutritional status, fat-soluble vitamin deficiency, sarcopenia, maldigestion, reduced quality of life, and glycemic variability. Diagnostic criteria are reviewed with particular emphasis on fecal elastase-1 as a widely accessible screening marker. The article provides an overview of current evidence on the efficacy of pancreatic enzyme replacement therapy (PERT), particularly with pancrelipase, which not only alleviates symptoms of maldigestion but also improves glycemic control, nutritional indices, reduces the frequency of hypoglycemia, and attenuates systemic inflammation.

Data from clinical studies confirm the safety and efficacy of long-term PERT even in patients without overt signs of EPI. The need for the development and implementation of national clinical protocols for EPI screening and management in DM, aligned with modern international guidelines (UEG, AGA, ESPEN), is emphasized. These approaches have the potential to improve metabolic control, nutritional status, and reduce diabetes-related complications, especially in patients with comorbid conditions.