Managing diabetes in patients with chronic liver disease.

Diabetes and chronic liver disease (CLD) are common long-term conditions in the developed and developing world. The 2 conditions often coexist, and there is evidence to suggest that diabetes can have a significant adverse effect on patients with CLD, leading to increased complications and premature mortality. While diabetes, nonalcoholic fatty liver disease, and nonalcoholic steatohepatitis (NASH) appear to have common origins related to obesity and insulin resistance, diabetes is also common among patients with alcoholic and viral CLD. In patients with NASH, improvement in metabolic indices appears to reduce the progression of CLD. It is not clear whether improving glycemic control in other forms of CLD leads to improved outcomes. Managing diabetes in patients with CLD can be challenging because many antihyperglycemic therapies are contraindicated or must be used with care. Metformin and pioglitazone may be useful in patients with NASH, but sulfonylureas and insulin must be used with caution, as hypoglycemia may be a problem. Insulin doses frequently need to be reduced in patients with CLD. Newer glycemic agents have not been widely used in patients with CLD, but bariatric surgery may lead to significant improvement in liver indices in patients with NASH. Management of patients with diabetes and CLD may be enhanced by using a multidisciplinary approach.