Abnormal liver tests and NAFLD in diabetes: A primary care approach
Sarah Davies
GP, Cardiff
● Abnormal liver function tests are very common in primary care – look for patterns and make an active diagnosis if possible.
- ALT the most abnormal = hepatic cause.
- Alkaline phosphatase the most abnormal = cholestatic cause; can be from bone – if GGT also elevated then liver cause.
- AST – less liver-specific than ALT, sensitive indicator in alcoholic liver disease.
- GGT – in liver but not bone. Commonly elevated due to obesity and alcohol. Non-specific for liver disease but good predictor of liver mortality.
● NAFLD is common and not benign, especially in people with metabolic syndrome or type 2 diabetes. Can progress to steatohepatitis and fibrosis. Primary care role:
- Identify and make active diagnosis.
- Assess likelihood of significant fibrosis (FIB-4, NAFLD fibrosis score – see RCGP liver disease toolkit) and refer if required.
- Support to achieve weight loss.
- Cardiovascular risk management. Statins are generally safe: no need to “over-monitor LFTs”.
- Potential for benefit from newer diabetes medications (GLP-1 RAs and SGLT2 inhibitors), although not yet licensed for this indication.
● Take-home point: NAFLD is not a benign condition – that raised ALT requires action!
Resources
- RCGP liver disease toolkit – open-access and includes links to tools and calculators as well as additional e-learning resources
- British Society of Gastroenterology Guidelines on the management of abnormal liver blood tests
- NICE NG46: NAFLD assessment and management
- All Wales abnormal LFT pathway
Managing diabetes in the elderly and frail
Chris Cottrell
Diabetes Specialist Nurse, Swansea Bay University Health Board
● Diabetes management in older adults is complicated by frailty, comorbidities and polypharmacy.
● Undertake a frailty assessment using a recommended tool, such as the electronic Frailty Index or Rockwood Scale, and use it to guide agreement of glycaemic targets.
● Frailty may be improved by simplifying, switching or stopping therapies to avoid hypoglycaemia, falls, hyperglycaemia, weight loss and sarcopenia.
● Consider de-escalation when appropriate – discuss with the person with diabetes and carers so everyone understands it is to ensure safety and improve quality of life, rather than “giving up” on providing care.
● Individualise glycaemic targets after discussion, depending on personal preferences, comorbidities, frailty, polypharmacy risks, likelihood of benefit or harm:
Resource
- National Advisory Panel on Care Home Diabetes Strategic document of diabetes care for care homes
Insulin in practice
Julie Lewis
Nurse Consultant, Primary Care Diabetes, Central Area, North Wales
● A perception of mystery and art to insulin management exists in clinical practice that can create delays to initiating and adjusting this very effective treatment for type 2 diabetes.
● Matching the insulin profile to the person’s specific requirements is key to insulin being an effective therapy choice.
- Glucose targets need to reflect the needs of the individual.
- Consider the support that may be needed to administer and monitor this treatment.
● A thorough understanding of the person’s glucose profile will inform an appropriate insulin regimen choice.
- Self-monitoring of blood glucose (SMBG) is the standard approach to obtain glucose profiles. However, NICE NG28 now supports the use of flash glucose monitoring in certain type 2 diabetes situations.
● Continuing other glucose-lowering therapies: use the guidance to inform a safe and individualised approach:
- Sulfonylureas: Reduce by half or consider stopping. Can re-introduce if needed.
- Metformin: Continue if tolerated/eGFR permits.
- Other oral therapies/injectables: What benefit are they adding (e.g. renal/cardiovascular disease/weight management)?
- Review safety to continue and/or impact of discontinuation (concomitant use of therapies for other conditions; e.g. heart failure).
- Reinforce guidance (e.g. sick-day rules, hypoglycaemia recognition and treatment).
● Insulin initiation:
- Refer to British National Formulary for starting dose advice.
- A lower starting dose is acceptable provided there is active dose adjustment thereafter.
- Use a checklist to guide the process of initiation: confirms what has been covered and records important advice.
● Ongoing management/support:
- Utilise insulin education programmes whenever possible to improve self-management competence.
- Insulin dose adjustment is a fundamental factor to assure insulin effectiveness. This cannot be completed safely without glucose data.
