Expert Blog

T2DM and Fatty Liver Disease: Is What’s Good for the Gander Good for the Goose?

Kim C. Dixon, MD
General Internist

Fatty liver disease is the most common cause of chronic liver disease in North America[1] and is becoming one of the top reasons for liver transplantation. Fatty liver causes inflammation that can lead to fibrosis, cirrhosis, and hepatocellular carcinoma. The physiologic relationship between type 2 diabetes mellitus and fatty liver disease is complex and multifactorial. A recent study in The Endocrine Society’s Journal of Clinical Endocrinology & Metabolism (JCEM) found that individuals with fatty liver were five times more likely to develop type 2 diabetes than those without fatty liver.[2] However, researchers are only beginning to unravel the mysteries surrounding the relationship between type 2 diabetes and fatty liver as it applies to large patient populations. In the meantime, clinicians are left to treat individuals with type 2 diabetes and/or fatty liver disease in light of existing evidence.

Already we know that lifestyle modifications that improve fatty liver, including diet, exercise, and weight management, are also beneficial for type 2 diabetes and should be encouraged for all patients. As clinicians individualize therapy for patients with type 2 diabetes, moreover, they should consider fatty liver disease.
Consider the following patient scenario: A 50-year-old male with type 2 diabetes presents for a follow-up visit. The diabetes is currently managed with diet and metformin 1000 milligrams BID. On exam, his BMI is noted to be 33. Laboratory evaluation reveals liver enzymes roughly two times normal and an HbA1C of 8%. Evaluation of the elevated liver enzymes leads to an abdominal ultrasound that establishes the presence of fatty liver disease. Lifestyle modification is strongly encouraged, including diet, exercise, and weight loss.
To improve diabetes control, a second medication is indicated, but which one? Thiazolidinediones are insulin sensitizers, and have been shown to reduce fat in the liver; however, they are associated with weight gain and have been under increased scrutiny with new warnings from the FDA regarding Avandia™. Sulfonylureas are associated with weight gain and are metabolized by the liver and therefore need to be used cautiously in the setting of obesity and fatty liver disease. A GLP-1 receptor agonist (exenatide and liraglutide being the only current FDA approved medications) could be added, but requires daily injections. A DPP-4 inhibitor may be a good choice as a second agent, and we will hopefully have more evidence in the future to evaluate efficacy for this particular patient population. Until then, clinicians will continue to do what they do best–treat patients with type 2 diabetes and fatty liver on an individual basis utilizing the limited evidence that exists for these populations. Sharing observations and experiences from our practices can be helpful, too, so please feel free to share them on this blog.


Submitted by Doron Schneider on

Thank you for this thoughtful blog. As you indicate - this all too common scenario requires a patient centered approach to decision making. In the absence of high quality data a review of risks and benefits for each agent should be discussed with the patient. These attributes (including the likelihood to positively impact on NAFLD) are summarized elegantly in the recent ACE gylcemic control algorithm. Readers should stay tuned given the rapidly evolving literature in this area. Separately, given the prevalence of Hepatitis C in the US I would ensure testing for this was part of the workup of his liver

Submitted by Kim Dixon on

Yes - excellent point, Doron! I rather reflexively order Hepatitis B and C studies on patients with elevated liver enzymes, unless previously documented. In the setting of elevated enzymes, I also frequently order ferritin/iron studies (Hemochromatosis screen) and consider getting ceruloplasmin levels (Wilson's disease screen) and/or alpha-1 antitrypsin although these are found much less frequently than Hepatitis B and C!

Submitted by John Leahy, MD on

Fatty liver (NASH) has become a huge health problem. I just finished the endocrine session with our first year medical students - it's grouped with GI diseases - and I was fascinated to see our students had had drilled into them that fatty liver is the number one cause of chronic liver disease/cirrhosis. Your blog points out the dilemma of therapy. TZDs have been shown to be beneficial in high profile papers, but most clinicians are wary of those drugs these days, and things revert fairly quickly when the TZD is stopped. Also metformin is probably helpful, but your patient (and many of the patients in general doctors' practices) are already on that drug. Incretin drugs - not sure. So we are left to recommend lifestyle and maybe insulin for better control - doesn't feel too high tech for such an important health issue.

I was interested that your patient had doubled transaminases. Unfortunately that is not always true. We are taught to look for fatty liver by LFT screening, but many patients have normal or only minimally elevated values. What is your experience in whom and how to screen?

Submitted by Kim Dixon on

Ah yes, whom and how to screen for fatty liver - a great question! Certainly patients with elevated liver enzymes warrant screening. For "at-risk" patients with normal liver enzymes there are no clear guidelines I am aware of and I usually defer to a golden rule I learned in residency - only order the test when the result will change management. Probably the best screening mechanism currently is ultrasound, as it is non-invasive, doesn't require contast or radiation exposure and is relatively inexpensive. Moncler Women Vests, Canada Goose Bombers, Canada Goose Hoodies, Golden Goose Francy, Valentino Pumps, Nike Air Yeezy, Moncler Kids Coats, Golden Goose Man, Air Jordan 4, Valentino Sneakers, Moncler Women Jackets, Alexander Mcqueen Woman, GS Air Jordans, Jimmy Choo Heels, Giuseppe Zanotti Sneakers, Golden Goose Ball Star, Valentino Flats, Canada Goose Sale, Moncler Scarves Hats, Golden Goose Sale, Balenciaga Shoulder Bags, Golden Goose May, Valentino Slides, Golden Goose 2.12, Valentino Flats, Air Jordan 8, Golden Goose V Star, Nike LeBron 15, Moncler Men Jackets, Balenciaga Women Sneakers, Golden Goose Ball Star, Air Jordan 13, Golden Goose Slide, Common Projects Man, Golden Goose May, Moncler Women Coats, Valentino Pumps, Golden Goose Slide, Golden Goose Francy, Moncler Men Vests, Moncler Kids Vests, Air Jordan 11, adidas Yeezy Boost 350, Nike Air Foamposite, Golden Goose Francy, Valentino Ballerinas, Golden Goose Outlet, Golden Goose Ball Star, Air Jordan 4, Golden Goose V Star, Balenciaga Shoes, Moncler Accessories, Moncler Women Vests, Valentino Pumps, Moncler Men Coats, Golden Goose Starter, Golden Goose Superstar, Golden Goose Francy, Golden Goose Sneakers, Golden Goose V Star, Golden Goose Scarpe, Moncler Women Jackets, Moncler Men Jackets, Valentino Sandals, Golden Goose May, Moncler Women Jackets, Moncler Women Boots, adidas Yeezy Boost 350 V2, Valentino Flats, Golden Goose Starter, Canada Goose Vest, Balenciaga Outlet, Golden Goose Mid Star, Golden Goose Slide, Moncler Men Jackets, Valentino Slingbacks, Nike LeBron 15, Balenciaga Backpacks, Golden Goose V Star, Golden Goose Slide, Air Jordan XXXI, Air Jordan 1, Golden Goose Tennis, Golden Goose Mid Star, Canada Goose Snow Buntings, Golden Goose Starter, Nike Air Foamposite, Canada Goose Coat, Moncler Scarf, Golden Goose May, Air Jordan GS, Air Jordan 9, Moncler Men Coats, Golden Goose Starter, Golden Goose Superstar, Valentino Sandals, Nike LeBron 16, Golden Goose, Valentino Slides, Golden Goose May, Air Jordan 8, Golden Goose May, Moncler Sale, Jimmy Choo Flats, Moncler Men Vests, Golden Goose Super Star, Nike Air Yeezy, Golden Goose V Star, Balenciaga Crossbody Bags, Valentino Sandals, Golden Goose 2.12, Balenciaga City Bags, Common Projects Sale, Golden Goose Starter, Alexander Mcqueen Man, Golden Goose Mid Star, Valentino Sneakers, LeBron James Jerseys, Balenciaga Caps, Valentino Sandals, Valentino Ballerina Flats, Canada Goose Parka, Golden Goose Slide, Golden Goose Shoes, Jimmy Choo Sale, LeBron 16, Valentino Outlet, Golden Goose Sneakers, Valentino Sneakers, Valentino Sneakers, Golden Goose Superstar, Golden Goose Mid Star, Moncler Men Coats, Moncler Women Coats, Air Jordan 6, Valentino Shoes, Air Jordan 3, Golden Goose V Star, Golden Goose Superstar, Common Projects Woman, Golden Goose Woman, Golden Goose Mid Star, Canada Goose Hoody, Golden Goose Ball Star, Golden Goose Francy, Valentino Outlet, Air Jordan 9, Air Jordan 10, Golden Goose Tennis, Jordan 12 Bulls, Balenciaga Tote Bags, Golden Goose Francy, Golden Goose Starter, Canada Goose Parkas, Balenciaga Clutch Bags, Moncler T Shirts, Moncler Sale, Giuseppe Zanotti Outlet, Air Jordan 12 Bulls, Canada Goose Jacket, Moncler Women Vests, Canada Coose Sale, Air Jordan 12, Air Jordan 6, Canada Goose Bomber, Valentino Pumps, Alexander Mcqueen Sale, Moncler Kids Jackets, Canada Goose Vests, Air Jordan 5, Valentino Sale, Moncler Men Vests, Valentino Slides, Air Jordan 10, Golden Goose Superstar, Golden Goose Ball star, Golden Goose Slide, Air Jordan 5, Air Jordan 12, Air Jordan 13, Nike Kyrie 3, Golden Goose Starter, Canada Goose Coats, Golden Goose Ball Star, Canada Goose Accessories, Moncler kids, Nike Kyrie 4, Valentino Slingbacks, Moncler Kids, Valentino Ballerinas, Valentino Slides, Golden Goose Superstar, Moncler Women Coats, Golden Goose V Star, Krie 4, Air Jordan 11, Canada Goose Jackets, Golden Goose, Balenciaga Men Sneakers, adidas Yeezy Boost 350 Infant, Golden Goose Slide, Balenciaga Sale, Golden Goose Mid Star, Air Jordan 3, Golden Goose Francy, Moncler Sale

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