Clinical Insight · Hepatology & Metabolic Medicine
Diabetes in
Liver Disease
What every hepatologist needs to know
about safe glycaemic management
Dr. Sangeetha Thanaraj FRCP (London)
Consultant Gastroenterologist & Advanced Endoscopist
The Metabolic Medicine · Worldwide via Zoom
The Metabolic Medicine · Worldwide via Zoom
Diabetes affects 30–40% of patients with cirrhosis and up to 70% with MASLD — yet HbA1c is unreliable, hypoglycaemia risk is high, and most oral agents need reconsideration.
Key Clinical Principles
HbA1c Is Unreliable
Anaemia & shortened RBC lifespan falsely lower HbA1c. Use CGM or glycated albumin instead.
Hypoglycaemia Risk
Impaired glycogenolysis in cirrhosis → nocturnal hypoglycaemia. Avoid sulfonylureas in CTP-B/C.
Stratify by Child-Pugh
CTP-A: most agents tolerated. CTP-B: restrict. CTP-C: insulin is the only safe choice.
GLP-1 RA for MASLD
Semaglutide reduces liver fat, ALT & MASH histology. Preferred agent across F0–F3 fibrosis.
Drug Safety — Child-Pugh Snapshot
Insulin — Preferred in CTP-B/C
GLP-1 RA — Safe CTP-A/B
Metformin — Caution CTP-B
SGLT2i — Caution CTP-B
Sulfonylureas — Avoid B/C
Metformin / SGLT2i — Avoid CTP-C
MASLD Treatment Pathway (ADA 2025)
F0–F1
Minimal Fibrosis
GLP-1 RA
± Pioglitazone
± Pioglitazone
F2–F3
Moderate Fibrosis
GLP-1 RA
± Resmetirom
± Resmetirom
F4
Cirrhosis
Insulin-based
Hepatologist-led
Hepatologist-led
Post-Transplant
PTDM
Insulin early
then GLP-1 RA
then GLP-1 RA
💡
Diagnose with OGTT, not fasting glucose alone. Postprandial hyperglycaemia predominates in hepatogenous diabetes — fasting glucose is often deceptively normal in cirrhosis.
Specialist metabolic medicine
consultations — worldwide via Zoom
consultations — worldwide via Zoom
Phone: 70948 30003
WhatsApp: 96267 30003
drsangeethathanaraj@gmail.com
The Metabolic Medicine
Based on ADA 2025 · EASL-EASD-EASO · AASLD 2023