It is well known that there is an association between diabetes and many forms of liver disease including elevated liver enzymes, fatty liver, cirrhosis, viral hepatitis, and hepatocellular carcinoma. Since the liver is the main organ that carries drug metabolism, one would expect changes in pharmacokinetics and pharmacodynamics of most antidiabetic drugs. This might lead, at least theoretically, to a change in their efficacy or the occurrence of adverse effects.
In my opinion, chronic liver patients with diabetes are candidates for insulin therapy. Insulin is by far the safest option in this particular scenario, since it doesn't carry along the potential hepato-toxicity and risk for metabolic acidosis of other anti-diabetic agents.
Best regards,
Yes, definitely insulin. By far the most effective antidiabetic treatment, and the safest in that context of concomitant chronic liver disease
Insulin therapy is still the safest in diabetic patients with co-morbidity like chronic liver disease.
I too agree with Dr.Juan. Insulin will not cause hepatotoxicity. You can also take Alpha amylase & Alpha- Glucosidase inhibitors such as Acarbose and Voglibose, since they function in the intestine.
The best answer is pioglitazone. This agent reverses fatty liver and lower liver enzyme levels. It is hepatoprotective.
Only Insulin. Insulin may decrease the speed of progression of chronic liver disease.
Liver disease caused by diabetes or insulin resistance treatment should address the cause of the disease which is the metabolic disruption associated it. That should be separated from end stage liver disease associated with other causes that is also associated with diabetes .Giving insulin in a patient that suffers from insulin resistance and high basal insulin or proinsulin levels is like putting oil on the fire .therefore as I mentioned in my previous notes evaluation of where the patient is in regard to pancreatic reserve is extremely important to try to prevent total endocrine pancreatic exhaustion. If insulin resistance is present with high basal insulin the goal should be to decrease baseline insulin resistance and make insulin work more efficiently. The problem is the side effect of most of the medications on the market, especially with associated liver disease. so far metformin is rather safe specially used at lower dosage , oral ileal hormones stimulation by itself or in combination with lower dose ddp4 inhibitors seems to work also well for both diabetes and liver at the same time . At the end of the road if the pancreas reserve for insulin secretion is gone, the only thing available is insulin. Keeping in mind you will be controlling the glucose levels, but not preventing the vascular complications, and you are likely to increase patient weight which will be controversial if the patient main problem is diabetes and steatohepatitis associated with obesity. Future research on pancreatic regenerations in vivo has started and a new chapter for diabetic treatment is on the horizon.
Thank you all for your contributions. To summarize one can conclude that:
1. Metformin, because it is not metabolized by the liver, is rather safe for diabetic patients with liver disease, but dose adjustement is necessary especially in advanced cases for fear of producing lactic acidosis.
2. Alpha-glucosidase inhibitors act locally and are safe and as reported in the literature, they are even advantageous in case of encephalopathy. They can be used in combination with metformin.
3. Pioglitazone as mentioned is hepatoprotective and may be useful, but it should always be remembered that it belongs to a family of drugs that might cause liver damage, even if it is a type of idiosyncrasy.
4. Insulin is metabilized by the liver, it will aggravate insulin resistance and hyperinsulinemia but it is safe in patients with end stage liver disease.
5. DPP-4 Inhibitors target insulin resistance which is an important target in Type II diabetes.
The conclusion , in my opinion is, treatment of diabetics with liver disease should be tailored or individualized, based on the nature and stage of both diabetes and liver condition. Doses and dose inervals should be checked regularly based on routine blood tests.
That was based on your comments, dear colleagues, thank you.
I agree with Joseph Fayad that the goal should be to decrease baseline insulin resistance and make insulin work more efficiently and also that the problem is the side effect of most of the medications on the market,. Could I therefore suggest that we try a different tack? It is well documented that stress causes increase in Omental fat and consequently Fatty liver, therefore the practice of the of Savasana (a Yogic practice) could be helpful . Look up Savasana on the internet. The practice of Uddiyana and Nauli can also be helpful in reducing Omental fat. Reduction of Omental fat can increase insulin sensitivity. It is a bit harder than oral or injectable insulin but would help considerably without side effects. A yoga teacher could help with Uddiyana and Nauli but the internet could also provide information.
It is well know that Diabetes and Chronic Liver Disease often coexist. Diabetes, NALD (Non Alcoholic Liver Disease) and NASH (Non Alcoholic SteatoHepatitis) share common pathophysiology related to Insulin resistance and Obesity. Good diabetes control will reduce the progression to Chronic Liver disease (CLD) in patients with NASH. As mentioned by some colleagues, managing diabetes in CLD can be quite challenging because many antihyperglycemic drugs in patients with CLD are either contraindicated or can be used with great caution to avoid additional complications. Management of such patients requires multidisplinary approach. Sulfonylureas and even Insulin should be used only with great caution and might need lowering the dosages because of the potential high risk of hyoglycemia, however pioglitazone and Metformin could be useful in patients with NASH. Bariatric surgery also can be an option in selected cases as it may result in considerable improvement in liver indices in patients with NASH.
I would like to pin point that monitoring diabetes control by glycated hemoglobin HbA1c will not be reliable in patients with CLD, however diabetes control monitoring can be laid on self monitoring blood glucose ( Blendea MC, Thompson MJ, Malkani S. Diabetes and chronic liver disease: Etiology and Pitfalls in monitoring. Clinical Diabetes, 2010; 28(4):139-144.)
- Badges
- Science topic
- Similar topics
- Medicine
- Disease
- Infectious Diseases