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Relationship between type 2 diabetes and liver disease

by Diane Dungey
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People with type 2 diabetes are at increased risk of developing liver disease and should be screened for liver disease even if they have no symptoms, said Mary E. Rinella, M.D., a transplant liver specialist at the University of Chicago Medicine. .

The opposite effect may also occur. The liver disease may have led to her developing type 2 diabetes, according to a recent study highlighting the link between the two diseases.

Still, awareness of the link between diabetes and liver disease “remains very low,” says Rinella, who is also director of the Metabolic Liver Clinic at the University of Chicago Medicine.

Type 2 diabetes can be diagnosed with a simple blood test. “We really want to get the situation under control quickly,” Rinella said. “What we can all do is try to prevent the progression of the disease in front of us.”

That’s why Rinella recently wrote a recommendation for the American Association for the Study of Liver Disease (AASLD) recommending FIB-4 testing for people with diabetes.

FIB-4 is used to screen for metabolic dysfunction-associated fatty liver disease (MASLD) (formerly known as non-alcoholic fatty liver disease), which affects 7 out of 10 people with type 2 diabetes. Calculations are based on routine blood tests used.

How type 2 diabetes worsens liver disease

One of the liver’s main functions is to maintain healthy blood sugar levels. Insulin, a hormone made by the pancreas, acts as a messenger that alerts cells to take up glucose from the blood.

However, when the liver is damaged by fat deposits, scarring, or cirrhosis, those cells become less responsive to insulin signals. The pancreas responds by releasing more insulin until it can’t keep up.

This insulin resistance is the basis of type 2 diabetes, and liver disease can spiral and progress unnoticed until symptoms such as jaundice, fatigue, gastrointestinal bleeding, bloating, and confusion appear.

“Most patients with liver disease go undiagnosed, even in advanced cases,” Rinella says. “By the time symptoms appear, the situation is often far advanced and irreversible.”

Early testing and intervention are important. The development of cirrhosis is the most common reason for the need for a liver transplant, said Rinella, who is also a co-author of the practice guidelines published in 2023 by AASLD and the American Society of Clinical Endocrinology.

“If you catch liver disease early, for example when you just had MASLD without severe scarring, it’s completely preventable so you don’t have to worry about cirrhosis, liver cancer or transplant,” she says.

Preventive treatments and medicines you should know about

Exercise and a diet low in carbohydrates and saturated fat can promote weight loss and help improve insulin sensitivity in the body, which is beneficial for people with liver disease and diabetes.

Many people make changes with guided support, says Sara Wirth, M.D., a registered dietitian at Chicago Medicine who helps MASLD patients reach their ultimate goals through small lifestyle modifications. It has been extremely successful.

“To halt the progression of liver disease, a reduction of 7 to 10 percent of total body weight needs to be achieved,” Dr. Wirth said.

Semaglutide, the active ingredient in Ozempic, Wegovy, and Rybelsus, can be prescribed to help some patients lose weight. Bariatric surgery is also an option, Rinella said.

She expects the U.S. Food and Drug Administration to approve the drug, resmetirom, soon. This would be the first drug to treat metabolic dysfunction-associated steatohepatitis (MASH), a more advanced stage of MASLD characterized by inflammation and scarring of the liver.

Rinella said other options could be on the table. Tirzepatide, branded Mounjaro, significantly reduced liver fat in patients in a recent study, and the experimental drug letartortide has shown promise in halting the progression of, and possibly reversing, liver disease.

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