Diagnosis and management of pancreatic exocrine insufficiency (PEI) in diabetes mellitus: A national expert consensus from India

Pancreatic exocrine insufficiency (PEI) affects approximately 25% of type 2 diabetes mellitus and 50% of type 1 diabetes mellitus patients but remains substantially underdiagnosed and undertreated in clinical practice. This national expert consensus provides evidence-based guidance on the epidemiology, pathophysiology, diagnosis, management, and monitoring of PEI in patients with diabetes mellitus. A multidisciplinary panel of Indian specialists representing diabetology, gastroenterology, pancreatology, and endocrinology conducted a comprehensive literature search across PubMed/MEDLINE, Embase, and the Cochrane Library. Consensus statements covering six domains were drafted, refined through two iterative review rounds, and finalized by formal consensus. Eighteen consensus statements were finalized across epidemiology, pathophysiology, diagnosis, management, monitoring, and patient outcomes. PEI prevalence in Indian populations ranges from 23.9% in type 2 diabetes mellitus to 22.9% in type 1 diabetes mellitus. The pathophysiology involves β-cell and α-cell dysfunction, autonomic neuropathy, glucotoxicity, pancreatic fibrosis, and acinar autoantibodies. The consensus recommends fecal elastase-1 testing (threshold < 200 µg/g) as the confirmatory diagnostic tool, pancreatic enzyme replacement therapy at 25,000–50,000 lipase units with meals, routine assessment of fat-soluble vitamin status, and clinical monitoring. PEI is a prevalent, underrecognized complication of diabetes mellitus requiring systematic screening. Symptom-based recognition, testing and pancreatic enzyme replacement therapy, nutritional supplementation, and glycaemic monitoring can break the cycle of malnutrition and glycaemic instability in diabetic patients.