1, the incidence of chronic liver disease combined with diabetes mellitus
The incidence of diabetes combined with chronic hepatitis B or C is significantly higher than that of the general population, the incidence of diabetes combined with chronic hepatitis is 10.25%, the incidence of diabetes combined with cirrhosis is 13%, of which the incidence of diabetes combined with chronic hepatitis C is 12.6%-32%, significantly higher than the control population, indicating that chronic liver disease is a high-risk group for the development of diabetes.
2, why chronic liver disease “favor” diabetes
The liver is a very important organ of the human body, which has many functions such as detoxification, synthesis, decomposition and metabolism. The main components of what we eat every day are sugar, protein and fat, most of which have to be biotransformed by the liver and become substances that the body can use itself. Therefore, when chronic liver parenchymal damage reaches a certain level, glucose tolerance is progressively reduced leading to the eventual development of diabetes in some of these patients. In addition, the hepatitis virus itself, especially the hepatitis C virus, directly interferes with the insulin signaling process, leading to insulin resistance, thus greatly increasing the chance of diabetes in patients with chronic liver disease.
3.What are the characteristics of chronic liver disease combined with diabetes mellitus
The symptoms of chronic liver disease combined with diabetes mellitus, such as drinking more, urinating more, eating more and losing weight, are not obvious, and the symptoms of chronic liver disease often cover up the manifestation of diabetes mellitus or are confused with the similar symptoms of diabetes mellitus, plus the liver’s ability to regenerate glucose is reduced, resulting in the rise of fasting blood glucose is not obvious. In addition, patients with liver disease have a reduced ability to regenerate glucose, resulting in a less pronounced increase in fasting glucose and a predominant increase in postprandial glucose, thus delaying the diagnosis of diabetes. For example, the symptoms of polyuria and thirst in patients with liver cirrhosis treated with diuretics are confused with polyuria and thirst in patients with diabetes mellitus, which makes patients ignore the existence of diabetes mellitus.
4. Principles of treatment for chronic liver disease combined with diabetes mellitus
First of all, liver disease should be controlled and diabetes should be treated at the same time. On the basis of reasonable diet and exercise therapy and active treatment of liver disease, it is recommended in principle to use insulin or insulin analogues as early as possible for patients with poor glycemic control, or to choose oral hypoglycemic drugs with the least possible damage to the liver according to the patient’s liver function. In case of liver failure or combined stress such as infection or surgery, insulin therapy must be applied. The choice of insulin therapy not only effectively reduces blood sugar, but also facilitates liver cell repair and liver function recovery. Patients with poor hepatic reserve function should especially apply insulin as early as possible. For patients with stable liver function, blood sugar can be controlled by diet therapy and drugs such as oral a glucosidase inhibitors, and in principle, biguanide preparations and thiazolidinediones should be used with caution.
Introduction of several drugs.
(1) Sulfonylurea hypoglycemic agents: mainly metabolized by the liver, with adverse effects of different degrees of liver damage, and are prohibited for patients with severe hepatitis, advanced cirrhosis, liver failure and liver cancer. For those with normal liver function or mild damage, you can choose drugs with less liver damage, such as Damacell and Glucophage.
2）Biguanide hypoglycemic drugs: Metformin is suitable for patients who are obese and have better liver function compensation. If cirrhosis, liver failure and renal insufficiency of patients with combined diabetes can be appropriate choice, there is a potential risk of lactic acidosis, should be disabled.
(3) а monoglucosidase inhibitor: The active ingredients are acarbose (Byosebol) and voglibose (Bexin tablets), which are suitable for patients with predominantly elevated postprandial glucose. Liver damage is minimal, and its safety is better than the first two hypoglycemic agents, but patients with decompensated cirrhosis often have digestive absorption disorders, and the use of this preparation may lead to increased abdominal distension, and it should be used with caution in patients with severe liver damage.
(4) Thiazolidinediones: Rosiglitazone can improve insulin resistance in type 2 diabetes, and its safety of liver damage is higher than that of troglitazone. There are safety risks in the application of chronic liver disease combined with diabetes, and it should be used with caution in patients with liver disease.
(5) Insulinotropic agent: Repaglinide is a flexible insulinotropic agent taken at mealtime to regulate mealtime blood glucose, mostly metabolized in the liver and excreted mainly through bile. Theoretically, it can be applied in mild hepatic insufficiency, but we generally do not apply it in patients with hepatitis and cirrhosis combined with diabetes mellitus.
(6) Insulin and insulin analogues: Insulin is currently used more actively in patients with type 2 diabetes, and for those who are not suitable for choosing oral hypoglycemic drugs or whose oral hypoglycemic drugs have failed, insulin therapy should be applied as soon as possible. It is more reasonable to inject short-acting type insulin before each meal, but for those with high fasting glucose can still add one medium-acting insulin before bedtime. Patients with chronic liver disease combined with diabetes can achieve satisfactory control of blood glucose insulin dose, relatively less than non-hepatitis patients, especially with the improvement of liver function to pay more attention to the appropriate reduction of dose.
5.Home care of liver disease combined with diabetes mellitus
(1) Pay attention to blood glucose testing
Most patients with liver disease combined with diabetes do not pay enough attention to glucose testing. Especially for patients who are not hospitalized, glucose testing directly affects the recovery and prognosis of patients with liver disease and diabetes. Therefore, it is extremely important to improve the importance of patients to blood glucose monitoring, and patients should learn the method of self-monitoring blood glucose. The blood glucose control standard for patients with diabetes alone is more strict, and it has a certain reference role for the control standard of chronic hepatitis combined with diabetes. However, patients with liver disease are prone to hypoglycemic reactions, and hypoglycemia is extremely detrimental to the recovery of the liver. Therefore, the control standard should be reduced accordingly, and the application of hypoglycemic drugs or insulin should be started in small doses and adjusted gradually to avoid hypoglycemia. Hypoglycemia often occurs before meals and at night. Severe hypoglycemia will not only damage the liver, but also endanger the life. To prevent and detect hypoglycemia, it is best to measure blood sugar promptly when there is discomfort such as heartburn and cold sweat. Also eat sugar water or dessert in moderation.
2) Proper use of insulin and glucose-lowering drugs
Biguanide hypoglycemic drugs: Phenobiguanide (hypoglycemia) and metformin (metformin, meticam) have hypotension and hypoxia occur when used in patients with liver disease.
Sulfonylurea hypoglycemic drugs: the dose and duration of sulfonylurea drugs such as euglycemia, damacell, mepiquat, and glucophage vary greatly among individuals, and some patients may have hypoglycemic reactions, so attention should be paid to post-medication observation.
Insulin is the ideal glucose-lowering drug to avoid liver damage. However, daily injection is not very convenient. Patients are often reluctant to accept it to affect their treatment. Therefore, patients should improve their compliance with insulin use. The beginning of insulin injection should be observed for hypoglycemia, and long-term users should also observe the injection site for abnormalities. Nowadays, human insulin preparations, such as Novolin and Eugenol, have very high purity and rarely show reactions such as subcutaneous hard knots and atrophy of fatty tissue. For patients who have just started using insulin, they should be patient and learn to use it by themselves, so as to prepare for the convenience of injecting it by themselves at home.
3) Pay attention to prevent skin infection
Patients with cirrhosis combined with diabetes mellitus have deep to moderate yellow staining and often have itchy skin, so avoid scratching to prevent skin breakdown and infection. If skin rupture and infection is found, it should be treated correctly in time to prevent ulceration and infection from worsening.
4) Mastering exercise therapy
Reasonable exercise is one of the basic methods to treat liver disease combined with diabetes, but the exercise mode and the amount of exercise for chronic hepatitis or cirrhosis patients with combined diabetes should depend on the severity of the disease.
In milder cases, exercise can be appropriate, and the amount of exercise can be measured by heart rate. So how to use heart rate to calculate the appropriate amount of exercise? Generally, you can count the pulse immediately after exercise, you can count 15 seconds, and then multiply it by 4 to get the heart rate per minute. The heart rate during exercise remains within the range of (220 – age) x 60-85%, which can be considered a suitable amount of exercise. For example, for a 60-year-old person, his or her post-exercise heart rate range = (220-60) x 60-85% = 96-136 beats/minute is appropriate.
Exercise should be performed one hour after a meal, and should last no less than 20 to 30 minutes, and generally no more than one hour.
You should try to choose your favorite exercise, there are various ways to exercise, such as running, swimming, playing ball, climbing, dancing, doing exercises, playing tai chi, etc. are all healthy exercises for the body and mind.
For patients with severe chronic liver disease or cirrhosis, exercise should be performed under the guidance of a doctor. Generally speaking, bed rest and liver protection treatment should be the main focus at this time. Once the condition is recovered, you can choose walking as a simple and easy way to exercise.
4）Know the precautions of insulin use
①Insulin should be applied under the guidance of a doctor
②The amount of staple food should also be strictly controlled after using insulin.
③Insulin should be injected subcutaneously 30 minutes before meals, but now some insulins are convenient and do not restrict the time, and can be injected during meals or just after a few bites or just after eating, without affecting the efficacy, such as Eugenol.
④The new drug must be replaced by expelling the air in the needle hole, and the syringe should be shaken to make the drug fully mixed before injection, and the needle should be kept under the skin for 5-6 seconds before it is pulled out.
⑤ When insulin is first applied, it should be under the guidance of the doctor and the dosage should never be adjusted without authorization. Regularly review the fasting and 2 hours postprandial blood glucose to prevent hypoglycemia and adjust the insulin dosage in time.
(6) Pay attention to the shelf life and storage methods, and usually place the injections and insulin in the refrigerator freezer door compartment.
(7) Before and after insulin injection, please pay attention to observe any hypoglycemic reactions, (such as: shivering, sweating, weakness, cold limbs, hunger, dizziness, drowsiness, rapid heartbeat, pale face, blurred vision, numbness or tingling of hands, feet and lips, anxiety, emotional instability, even unconsciousness or even coma, etc.)
6.Understanding the impact of alcohol and tobacco on the disease
Quit smoking and alcohol is very important for disease recovery. Tobacco smoke has more than 4,000 kinds of harmful substances, and more than 60 kinds are suspected or known carcinogens. Among them, nicotine is a neurotoxin and highly toxic substance. Cigarette tar also contains a large number of carcinogens, and the harmful substances in tobacco have to be detoxified in the liver, which increases the burden on the liver and affects recovery from liver disease. Alcohol consumption is even more harmful to the liver and diabetes. Alcohol can increase the synthesis of triglycerides in the liver, reduce the oxidation of lipids in the liver, and reduce the release of hepatic lipoproteins leading to fatty liver causing alcoholic hepatitis. The antiviral capacity of hepatocytes is significantly weakened after alcohol consumption, and viral replication indicators tend to be high. Large amounts of viral replication can aggravate hepatocyte necrosis. The stimulation of gastric mucosa by alcohol can also induce gastrointestinal bleeding in patients with portal hypertensive varices.
In conclusion, the quality of home care for liver disease combined with diabetes directly affects the recovery of this disease. I truly hope that my reminders in the above areas will serve to control the development of the disease and improve the quality of life. Finally, I wish you all a speedy recovery!