An Approach to the Management of Diabetes Mellitus in Cirrhosis: A Primer for the Hepatologist

Abstract

The management of diabetes in cirrhosis and liver transplantation can be challenging. There is difficulty in diagnosis and monitoring of diabetes as fasting blood sugar values are low and glycosylated hemoglobin may not be a reliable marker. The challenges in the management of diabetes in cirrhosis include the likelihood of cognitive impairment, risk of hypoglycemia, altered drug metabolism, frequent renal dysfunction, risk of lactic acidosis, and associated malnutrition and sarcopenia. Moreover, calorie restriction and an attempt to lose weight in obese diabetics may be associated with a worsening of sarcopenia. Many commonly used antidiabetic drugs may be unsafe or be associated with a high risk of hypoglycemia in cirrhotics. Post-transplant diabetes is common and may be contributed by immunosuppressive medication. There is inadequate clinical data on the use of antidiabetic drugs in cirrhosis, and the management of diabetes in cirrhosis is hampered by the lack of guidelines focusing on this issue. The current review aims at addressing the practical management of diabetes by a hepatologist.

Keywords: ADA, American Diabetes Association; AGI, Alfa Glucosidase inhibitors; BMI, Body mass index; CLD, Chronic liver disease; CYP-450, Cytochrome P-450; Dipeptidyl-peptidase 4, DPP-4; GLP-1, Glucagon-like peptide-1; HCC, Hepatocellular carcinoma; HCV, Hepatitis C virus; HbA1c, Hemoglobin A1c; IGF, Insulin-like growth factor; MALA, Metformin-associated lactic acidosis; NASH, Nonalcoholic steatohepatitis; NPL, Neutral protamine lispro; OGTT, Oral glucose tolerance test; SMBG, Self-monitoring of blood glucose; Sodium-glucose cotransporter 2, SGLT2; VEGF, Vascular endothelial growth factor; antidiabetic agents; antihyperglycemic drugs; chronic liver disease; cirrhosis; diabetes mellitus; eGFR, estimated glomerular filtration rates.

Figure 1

Prescribing insulin for diabetes mellitus in cirrhosis. FBG, fasting blood sugar; PPG, postprandial blood sugar; HRS, hepatorenal syndrome. ∗Basal analogs- Glargine, Detemir, or Degludec.

Figure 2

Algorithm of managing diabetes mellitus in cirrhosis. AGI. Alpha-glucosidase inhibitor, DPP-4i, dipeptidyl-peptidase-4 inhibitor; eGFR, estimated glomerular filtration rate; GLP-1ra, Glucagon-like peptide-1 receptor agonist; SGLT2i, sodium-glucose cotransporter-2 inhibitor.