Dr. Balaji Jaganmohan: a Case of Fibro calculus pancreatic diabetes [FCPD]

CASE OVERVIEW

Although Type 1 & Type 2 are the commonest forms of all diabetes, Diabetes Mellitus due to secondary causes has also been encountered in clinical settings. Fibro Calculus Pancreatic Diabetes [FCPD] is one of the unique & rare varieties of DM, secondary to chronic calcific pancreatitis. Chronic calculi resulting in inflammatory changes can affect both the exocrine and endocrine parts of the pancreas which eventually results in FCPD. A 51-year-old non-alcoholic South Indian Male with a diabetes duration of 8 years visited Dr. Balaji Jaganmohan’s clinic on 30/10/2014. He was diagnosed elsewhere to be a case of T2DM and treated with high doses of Glimepiride, Metformin, and Vildagliptin. He had FBS of 121 mg/dl, PPBS of 242 mg/dl & HbA1c of 7.1%. He was lean with a BMI of 19.2.
On further probing, he revealed that he had childhood H/O recurrent abdominal pain with the passage of oily stools [steatorrhoea]. He was diagnosed in the year 2011 as a case of chronic calcific pancreatitis with stones in the head of the Pancreas, evidenced by Abdominal Ultrasonography, CT Abdomen and Endoscopic retrograde cholangio pancreatography [ERCP] reports. He was managed with pancreatic sphincterotomy with stone extraction followed by sphincteroplasty with stenting in MPD. He further underwent pancreatic stone extraction procedure again in the year 2012 for a similar event of calcific pancreatitis.

DIAGNOSIS

He was diagnosed to be a case of Fibro Calculus Pancreatic Diabetes [FCPD] based on his clinical presentation, lab, and imaging reports and on further assessment, the Lab. Investigations revealed relatively low fasting C-Peptide level [1.49 ng/ml], high Amylase [106.8 U/L], and normal Lipase, LFT, Urea & S. Creatinine values.

RESULTS

He has been under treatment for the last 7 years with relatively good glycaemic control [HbA1C 7-8%]. His recent Lab. Investigation reports revealed FBS 108 mg/dl, PPBS 128mg/dl, HbA1C 7.4, T.Cholesterol 185 mg/dl, Triglyceride 190mg/dl, D 100mg/dl, S. creatinine 1.1 mg/dl,. He continues to take Basal bolus insulin along with SU and SGLT2i without experiencing hypoglycemia or other adverse events.

TREATMENT

His previous medications namely glimepiride 4mg BD, Vildagliptin 50 mg BD [contraindicated in Pancreatitis], and Metformin 500 mg BD were stopped. He was put on Gliclazide 60mg OD along with insulin Glargine at bedtime and insulin GluLysine TID [Basal- bolus], enzyme replacement therapy & Vit D Supplementation. He was also advised to have a low-calorie diet, physical exercise, and to self-monitor his blood glucose.
Owing to his corporate lifestyle, he gained some weight and glycemic control slightly deteriorated, hence Canagliflozin 100mg OD was started 3 years ago along with his ongoing treatment for better glycemic control and other metabolic benefits (SGLT2i given off-label and probably the first time in someone with FCPD).