Liver Disease in Diabetes: A Call to Action
Like millions of adults worldwide, our close family friend lived with undetected steatosis.
Up to 70% of people with diabetes have steatosis, which increases the risk for progressive liver disease. Unfortunately, much of the time, it is not discovered early enough.
Over 15 years ago, our friends’ steatosis progressed and quickly led to hepatocellular carcinoma. A cursory evaluation of his health history quickly highlights his risk of steatosis. He lived with diabetes for over ten years and had insulin resistance, as evidenced by his dark neck tan (acanthosis nigricans), hypertension, and a BMI well over 30. Even without any access to his lab data or complete medical history, we can easily assume that he was at risk for liver disease. Yet, he did not receive any diagnostic testing or nutrition counseling to address the silent inflammation that was wreaking havoc on his liver.
At 67, his steatohepatitis became evident as his confusion increased. His skin had a faint yellow tinge, and he “just wasn’t himself.” Months later, we were saying an early goodbye to a big-hearted, fearless man who loved his family and community and made a lasting impression on anyone he met.
We are not alone in this tragic story. The statistics are startling. About 70% of people with diabetes have steatosis, and of those, 50% are living with the more serious steatohepatitis, which can lead to severe liver fibrosis and scarring. Over time, these individuals are at risk of developing cirrhosis, liver cancer, and cardiovascular disease. Yet, we are only now catching up with this under-detected and often overlooked condition and its impact on individual and public health outcomes.
We can all become more actively involved in screening for liver disease and advocating for prompt action when it is detected. Together, we can save lives and share a message of hope!
Diabetes care and education specialists can Take Action!
According to the American Diabetes Association Standards of Care, here is a list of actions we can take to identify and prevent progression of liver disease.
- Lab Check: Encourage yearly evaluation of liver health and risk factors. Review annual ALT and AST levels and alert providers for values greater than 30 and evaluate Fib-4 Score.
- Calculate Fib-4 yearly to determine the risk of fibrosis and liver disease (you need the person’s age, ALT, AST, and platelet count). Encourage further imaging for those with elevated FIB-4.
- Take Action: For people with diabetes at higher risk of steatosis based on elevated insulin resistance (BMI 30+, cardiometabolic factors, age 50+), in addition to screening for liver disease, encourage immediate lifestyle changes that decrease steatosis risk and improve health – even before an official diagnosis!
- Lifestyle changes:
- Refer to an RD/RDN for MNT therapy. In the meantime, encourage movement toward the Mediterranean Diet and a 5-10% weight reduction.
- Strength training at least twice weekly and increased activity (150 minutes a week) to improve insulin sensitivity.
- Even small changes in waist circumference indicate decreased visceral adiposity. These critical lifestyle changes decrease hepatic lipotoxicity and promote healing.
More than lifestyle change is often needed. Medications to Treat and Address Steatosis
The following medication is the first FDA-approved treatment for NASH and fibrosis.
- Rezdiffra (resmetirom) – The U.S. Food and Drug Administration approved Rezdiffra (resmetirom) in March 2024, for the treatment of adults with noncirrhotic, non-alcoholic steatohepatitis (NASH) with moderate to advanced liver scarring (fibrosis), to be used along with diet and exercise. Rezdiffra is a partial activator of a thyroid hormone receptor; activating this receptor by Rezdiffra in the liver reduces liver fat accumulation. “Previously, patients with NASH who also have notable liver scarring did not have a medication that could directly address their liver damage,” said Nikolay Nikolov, M.D., acting director of the Office of Immunology and Inflammation in the FDA’s Center for Drug Evaluation and Research. “Today’s approval of Rezdiffra will, for the first time, provide a treatment option for these patients, in addition to diet and exercise.”
The following medications are not specifically FDA-approved to treat liver disease but are recommended in the setting of diabetes and metabolic-associated steatosis/steatohepatitis.
Since steatosis and type 2 diabetes share underlying alterations in pathophysiology, including insulin resistance, it is not surprising that agents used to treat type 2 diabetes have demonstrated benefit in treating metabolic-associated steatosis and steatohepatitis.
- Pioglitazone (Actos) reduces blood glucose, and several studies demonstrate it is an effective treatment for steatosis and steatohepatitis. It also reduces the progression of fibrosis and cardiovascular risk. Since pioglitazone can cause fluid retention and weight gain, avoid using it in those with heart failure.
- GLP-1 RAs—this class of medication not only lowers blood glucose but can also lead to significant weight loss and a reduction in visceral adiposity and hepatocellular lipid levels. Several studies demonstrate that it is an effective treatment for steatosis and steatohepatitis. It also reduces the progression of fibrosis and cardiovascular risk.
- SGLT-2 Inhibitors – Recent research published in JAMA reveals that in a retrospective study, SGLT-2 Inhibitors were associated with a higher likelihood of liver disease regression among those with metabolic dysfunction-associated steatotic liver disease and type 2 diabetes. According to Dr. Won Kim, the study’s lead researcher, “SGLT2 inhibitors were distinguished by their association with fatty liver improvement, surpassing other [oral antidiabetic drugs] known for their potential benefits in steatosis.” More research is needed, but since this class of medication lowers blood glucose plus decreases cardiovascular risk, it is already widely used for people with diabetes and insulin resistance.
- Statin Therapy – Lipid-lowering and antihypertensive meds need to be prescribed in people with steatosis as indicated. Statins are safe in individuals with steatohepatitis but avoid their use in those with decompensated cirrhosis.
A Final Note
Even though we lost our close friend due to undetected liver disease, I am hoping that by telling our story, all of us can become more actively involved in screening for liver disease and advocating for prompt action when it is detected. Together we can save lives and share a message of hope.
Coach Beverly
Resources: In addition to the ADA Standards, I utilized this article below, published in the Winter 2024 Edition of Diabetes Spectrum: Nonalcoholic Fatty Liver Disease: A Call to Action.
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