Exocrine Pancreatic Insufficiency in Diabetes: Association with Cardiovascular Disease and Insulin Therapy

Background/Objectives: Exocrine pancreatic insufficiency (EPI) is increasingly recognized in patients with diabetes; however, its clinical correlates remain poorly defined. This study aimed to determine the prevalence and clinical characteristics of EPI in patients with type 1 (T1DM) and type 2 diabetes mellitus (T2DM) and to evaluate its associations with diabetes-related complications and insulin therapy. Methods: A total of 200 patients with diabetes were screened, and 182 who met the inclusion criteria were included in the final analysis. EPI was diagnosed using fecal elastase-1 (FE-1). Clinical, biochemical, and complication-related data were collected. Factors associated with EPI were evaluated using univariate and multivariate logistic regression analyses. Among patients with T2DM, an inverse probability of treatment weighting-average treatment effect on the treated (IPTW-ATT) model was constructed to evaluate the association between insulin therapy and EPI. Propensity scores were estimated using baseline demographic and clinical covariates, and covariate balance after weighting was assessed using standardized mean differences (SMDs). Results: Exocrine pancreatic insufficiency was detected in 18.1% of patients, with prevalences of 21.2% in T1DM and 17.4% in T2DM. Cardiovascular disease was the only variable independently associated with EPI in multivariate analysis (OR = 3.25; 95% CI: 1.12-6.75; p = 0.028. Among patients with T2DM, insulin therapy was significantly associated with EPI in both unadjusted and IPTW-ATT analyses (weighted OR = 10.76; 95% CI: 1.85-62.76; p = 0.008) with a wide confidence interval reflecting sparse data. Cardiovascular disease also remained significantly associated with EPI in the weighted model (OR = 3.52; 95% CI: 1.22-10.15; p = 0.020). Conclusions: Exocrine pancreatic insufficiency is a clinically relevant condition in diabetes and shows a significant cross-sectional association with cardiovascular disease. In T2DM, insulin therapy was associated with a higher prevalence of EPI, although confounding by indication cannot be excluded. These findings suggest that evaluation of exocrine pancreatic function may be considered in high-risk diabetic subgroups, pending confirmation in prospective longitudinal studies.