Pancreatin Added to Standard Antihyperglycemic Therapy in Patients With Type 2 Diabetes

Glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) are the two primary incretin hormones secreted from the small intestine on ingestion of glucose or nutrients to stimulate insulin secretion from pancreatic β cells. They play a role in regulation of blood glucose levels, particularly postprandial glycemia. Lipids and carbohydrates are the most potent stimulators of incretin hormone secretion. Pancreatin is a mixture of digestive enzymes naturally produced by the pancreas, which is used as a medication supporting macronutrient digestion, especially in cases of exocrine pancreatic insufficiency. Evidence suggests that oral pancreatin supplementation enhances the incretin effect by increasing GIP and GLP-1 concentrations, and consequently insulin levels, which translates into a reduction in postprandial glycemia in patients with cystic fibrosis or chronic pancreatitis. Based on a randomized, placebo-controlled, double-blind study, we aim to evaluate the effect of pancreatin on the incretin effect and glycemic control in patients with type 2 diabetes without exocrine pancreatic insufficiency.

We plan to recruit a total of 100 patients with type 2 diabetes treated with oral antihyperglycemic drugs or insulin, either as monotherapy or in combination. Patients will be randomly divided into 2 groups:

• Group of 50 patients receiving pancreatin 25 000 U with up to 3 main meals daily for 3 months
• Group of 50 patients receiving placebo with up to 3 main meals daily for 3 months

Baseline assessment:

• Anthropometric parameters: body weight, height, waist-to-hip ratio, body composition (bioelectrical impedance analysis)
• Laboratory tests: aspartate aminotransferase, alanine aminotransferase, serum amylase, lipid profile, HbA1c, selected cytokines, average glucose concentration from the last 7 days before study start (glucometer - 4 measurements per day), data from the FreeStyle Libre2 continuous glucose monitoring system (2 weeks prior to study start): assessment of TIR (Time in Range 70-180 mg/dL), glycemic variability coefficient (CV), standard deviation (SD), mean glucose concentration, frequency and severity of hypoglycemia; daily insulin requirements from the last 7 days (for insulin-treated patients)

Assessment after study completion:

• Anthropometric parameters: body weight, height, waist-to-hip ratio, body composition (bioelectrical impedance analysis)
• Laboratory tests: aspartate aminotransferase, alanine aminotransferase, serum amylase, lipid profile, HbA1c, selected cytokines, average glucose concentration from the last 7 days before study end (glucometer - 4 measurements per day), data from the FreeStyle Libre 2 continuous glucose monitoring system (last 2 weeks of study): assessment of TIR, CV, SD, mean glucose concentration, frequency and severity of hypoglycemia; daily insulin requirements from the last 7 days (for insulin-treated patients).

Should pancreatin demonstrate a beneficial effect on glycemic homeostasis, these formulations could serve as a valuable adjunctive therapy for type 2 diabetes.