Concepts of Treating diabetes in chronic liver disease and different stages of cirrhosis

1. {
Concepts of management of
diabetes in Chronic liver disease
By Ahmed Elmoughazy
Internal medicine resident, Medical research institute, Alexandria
university

2. 70%
30%
Prevalence of Diabetes among CLD
No Diabetes
Diabetes
Garcia-Compean D, Jaquez-Quintana JO, Gonzalez-Gonzalez JA, Maldonado-Garza H. Liver cirrhosis and diabetes: risk factors, pathophysiology, clinical
implications and management. World J Gastroenterol. 2009 Jan 21;15(3):280–8.

3.  Patients with chronic liver disease have a high
prevalence of glucose intolerance and diabetes
because of the presence of
1. insulin resistance
2. β-cell dysfunction.

4. How to Monitor?

6. How to control ?

7.  If a patient has stable CLD and few other comorbidities,
metformin is likely to be reasonably safe, but the dose
should be decreased to a maximum of 1500 mg daily.
 The drug should be withdrawn if liver or renal function is
deteriorating, or in the setting of acute illness or
decompensation.
Metformin

8. Sulfonylureas and
meglitinides
 Because they are metabolized by the liver, their duration of
action may be prolonged in patients with CLD. Therefore:
1. They should be avoided or used with caution at low doses
in patients with T2DM and CLD.
2. Short acting glipizideis preferred.

9.  It may have a specific role in patients with CLD and diabetes,
particularly in patients with NAFLD and NASH, as a
randomized study showed improvement in histological indices
in patients with NASH who were treated with pioglitazone.
 Careful liver function test monitoring is indicated in all patients
commencing pioglitazone therapy.
Thiazolidinediones

10.  Sitagliptin & saxagliptin can be safely
used without dose adjustment.
 Vildagliptin is not approved in patients
with hepatic insufficiency.
DPP4-inhibitors

11.  Insulin therapy is the safest and most effective
antihyperglycemic therapy in patients with
CLD.
 It is the onlyapproved and safe wayto control diabetes in
Decompensated Chronic liverdisease.
 Dose may be decreased due to reduced hepatic
breakdown of insulin.
Insulin

12. Conclusion

13.  In compensated CLD, Oral hypoglycmic drugs
are legit to use with special precautions.
 Insulin remains the safest and the most
effective way to control diabetes in CLD
patients in general , and the only way to
manage DM in Decompensated liver disease
specifically.