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In the absence of sufficient enzyme replacement, vitamin D supplementation may be ineffective despite appropriate dosing, and patients with severe or refractory malabsorption may require alternative approaches such as water-miscible or liquid formulations, calcidiol (25-hydroxyvitamin D), or supervised non-oral therapies ( 6.5.3 Gastrointestinal complications Gastrointestinal complications in PDM reflect established consequences of exocrine pancreatic insufficiency and are managed according to current standard clinical pathways, rather than disease-specific surveillance protocols ( Persistent steatorrhea or unexplained weight loss in people with PERT may be indicative of small intestinal bacterial overgrowth (SIBO) or celiac disease and should therefore be referred for a gastroenterology assessment