**10. Treatment of endocrine insufficiency/CP-related DM**

CP-related DM (CP-DM) is the most frequent cause of pancreatogenic DM (which has also been referred to as type 3c DM). Biannual fasting glucose and glycated hemoglobin should be obtained to assess for diabetes in CP patients [70]. The management of type 3c diabetes follows general recommendations for diabetics.

A healthy lifestyle with regular exercise and a balanced diet should accompany medical treatment. Optimized pancreatic enzyme replacement therapy improves duodenal sensing and uptake of complex nutrients, thus stabilizes blood sugar levels. Due to a lack of counter regulation, patients with type 3c diabetes have an increased risk for hypoglycemia and should be counseled accordingly. The treatment of choice is often insulin, but in mild hyperglycemia (HbA1c <8%) metformin has also been recommended [2]. In addition to its glucose lowering effect, a meta-analysis of 12 observational studies showed that metformin reduced the risk of pancreatic cancer development in people with diabetes [125]. Sulfonylureas should be avoided. Although glinides, thiazolidinediones, α-glycosidase inhibitors, incretin-based therapies, and SGLT2 inhibitors have not been tested in randomized trials, they may be effective in certain cases [61]. In order to understand the pathogenesis better and to inform the prevention and treatment of CP-DM, a detailed characterization of changes in glucose homeostasis in CP DM compared to type 2 DM is required [61].
