Review
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Meta-Anal. Aug 31, 2019; 7(8): 380-388
Published online Aug 31, 2019. doi: 10.13105/wjma.v7.i8.380
Antidiabetic agents in patients with hepatic impairment
Athanasia Papazafiropoulou, Andreas Melidonis
Athanasia Papazafiropoulou, Andreas Melidonis, 1st Department of Internal Medicine and Diabetes Center, Tzaneio General Hospital of Piraeus, Athens 18536, Greece
ORCID number: Athanasia Papazafeiropoulou (0000-0002-7596-4942); Αndreas Μelidonis (0000-0003-0505-5708).
Author contributions: All authors equally contributed to this paper with conception and design of the study, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.
Conflict-of-interest statement: No potential conflicts of interest. No financial support.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Athanasia Papazafiropoulou, MD, MSc, PhD, Attending Doctor, Research Scientist, 1st Department of Internal Medicine and Diabetes Center, Tzaneio General Hospital of Piraeus, 1 Zanni and Afentouli Street, Athens 18536, Greece. pathan@ath.forthnet.gr
Telephone: +30-697-996483
Received: June 27, 2019
Peer-review started: June 29, 2019
First decision: July 31, 2019
Revised: August 7, 2019
Accepted: August 20, 2019
Article in press: August 20, 2019
Published online: August 31, 2019

Abstract

Chronic liver disease (CLD) often coexists with type 2 diabetes mellitus, making diabetes management a challenge to the clinician. It is well known that liver is the major site of drug metabolism, and, therefore, its impairment affects hepatic metabolism of many antidiabetic agents. Furthermore, patients with CLD have serious comorbidities such as impaired renal function, hypoalbuminemia, lactic acidosis, hypoglycemia and malnutrition, making their treatment even more difficult. On the other hand, most of the antidiabetic agents, with the exception of insulin, need dosage titration due to alterations to their pharmacokinetics in patients with CLD. For well-established antidiabetic treatments, like metformin and sulfonylureas there are studies regarding their dosage chance in these patients. However, despite the growing problem of management of diabetes in patients with CLD the existing literature data, especially on newer antidiabetic agents, are limited and, furthermore, no direct guidelines exist. Therefore, in the present review article we try to summarize the existing literature data regarding management of diabetes in patients with CLD.

Key Words: Hepatic impairment, Type 2 diabetes mellitus, Pharmacokinetics, Antidiabetic drugs

Core tip: Most of the antidiabetic agents, with the exception of insulin, need dosage titration due to alterations to their pharmacokinetics in patients with chronic liver disease (CLD). For well-established antidiabetic treatments, like metformin and sulfonylureas there are studies regarding their dosage chance in these patients. However, despite the growing problem of management of diabetes in patients with CLD the existing literature data, especially on newer antidiabetic agents, are limited and, furthermore, no direct guidelines exist. Therefore, in the present review article we try to summarize the existing literature data regarding management of diabetes in patients with CLD.



INTRODUCTION

Liver is one of the principal organs in carbohydrate metabolism due to its important role in neoglucogenesis and glycogenolysis[1]. A link between type 2 diabetes mellitus (T2DM) and chronic liver disease (CLD) was observed for the first time before almost 100 years[1,2]. Since then it is well-known that diabetes and CLD often coexist. Even more, presence of CLD increases not only T2DM complications but it is recognized as a cause of premature mortality in patients with T2DM[3]. On the contrary, diabetes per se has been recognized as a risk factor for CLD and hepatocellular carcinoma (HCC). It is estimated that about 30%-60% of patients with cirrhosis have T2DM[4]. In another study, the prevalence of T2DM in patients with CLD was varied between 18%-71%[5]. On the other hand, glucose intolerance is present in the majority of patients with CLD[6]. It is obvious, that there is a two-side relationship between T2DM and CLD making the management of these patients a challenge to the clinicians.

Since liver is the major site of metabolism for most of the antidiabetic agents, management of T2DM in patients with CLD is still challenging for the reasons that are listed below. First of all, patients with CLD have serious comorbidities such as impaired renal function, hypoalbuminemia, lactic acidosis, hypoglycemia and malnutrition[7,8]. Secondly, patients with CLD are more prone to acute kidney injury leading to accumulation of either drugs or their metabolites resulting in various adverse events[9]. Finally, patients with CLD develop malnutrition as the liver plays a key role in carbohydrate, protein, lipid, vitamin, and mineral metabolism and energy balance[10,11].

Liver is the major site of drug metabolism, and its impairment affects hepatic metabolism of drugs[12]. On the other hand, hypoalbuminemia, a result of protein deficiency[13], can cause serious toxicity by highly protein bound drugs since their free plasma concentrations are increased in CLD. Furthermore, the potential hepatotoxicity of some oral antidiabetic agents (OADs) associated adverse events favored by CLD makes management of T2DM in patients with CLD even more complex[4].

Until now, only limited literature data are available yet regarding the management of T2DM in patients with CLD[3,8]. Therefore, the aim of the present review is to summarize the existing literature data on the use of OADs and injectable agents in T2DM patients with CLD.

CLASSIFICATION OF LIVER IMPAIRMENT

The Child-Pugh score is currently used to assess the overall prognosis of CLD, mainly cirrhosis[14]. The Child-Pugh score is consisted of 5 clinical characteristics of liver disease: total bilirubin level, serum albumin concentration, prothrombin or international normalized ratio value, presence of ascitis and hepatic encephalopathy. Each measure is scored from 1 to 3, with 3 indicating most severe derangement. Patients are classified into 3 Child-Pugh classes (A-C): Child-Pugh A = 5-6 points, Child-Pugh B = 7-9 points, and Child-Pugh C = 10 or more points.

ANTIDIABETIC TREATMENT
Biguanides (metformin)

Metformin, a biguanide compound, is the first-line therapy for T2DM patients for almost half a century[15]. Its action is mediated by the inhibition of gluconeogenesis and glycogenolysis in hepatocytes[15]. Metformin undergoes renal excretion and is excreted unchanged by the kidneys[16].

One of the most life threating adverse events of metformin is lactic acidosis. However, it must be noticed that metformin might cause lactic acidosis in predisposed patients (with heart, renal and liver failure), a rather rare, however, adverse event of metformin therapy. In patients with CLD, there is an increased risk of low oxygen tension due to concurrent pulmonary or heart disease making lactic acidosis easy to happen. Even more, patients with CLD are at increased risk for sepsis or hemorrhage[17] making them vulnerable to lactic acidosis since metformin inhibits mitochondrial respiration in the liver[18]. It must be mentioned that lactic acidosis is rather a rare side effect of metformin since the incidence of lactic acidosis is 0.03-0.5 cases/1000 patient-years in metformin-treated population[19].

According to the existing studies, metformin therapy is safe in T2DM patients with cirrhosis, and further prolong patient’s survival time. A study in 22 T2DM cirrhotic patients showed that metformin therapy was related to overt hepatic encephalopathy. A possible pathogenetic mechanism proposed by authors was the inhibition of glutaminase activity[20]. Another study showed that metformin was related with reduced incidence of HCC and liver-related death/transplantation in T2DM patients with cirrhosis due to hepatitis C virus[21]. It is noteworthy that metformin therapy reduced the risk of death by 57% in T2DM patients with cirrhosis[22].

The only risk of metformin therapy in patients with CLD, as it is mentioned above, is lactic acidosis. Therefore, according to the ADA guidelines, it is recommend to avoid metformin therapy in patients with severe hepatic impairment (HI) or in binge drinkers due to high risk for lactic acidosis[15] (Table 1).

Table 1 Use of antidiabetic agent according to the degree of hepatic impairment.
Antidiabetic agentDegree of hepatic impairment (HI)
MetforminAvoid in severe HI
Sulfonylureas
GlimepirideAvoid in severe HI
GliclazideAvoid in severe HI
Glinides
RepaglinideAvoid in severe HI
NateglinideNo adjustment of dosage in mild to moderate HI
Alpha-glucosidase inhibitors
AcarboseWell tolerated
Thiazolidinediones
PioglitazoneSafe in Child-Pugh Class A patients. Should be avoided in Class B and C patients
DPP-4 inhibitors
SitagliptinWell tolerated
VildagliptinWell tolerated
SaxagliptinWell tolerated
AlogliptinWell tolerated
LinagliptinWell tolerated
GLP-1 receptor agonists
ExenatideWell tolerated
LiraglutideWell tolerated
LixisenatideWell tolerated
SGLT-2 inhibitors
CanagliflozinSafe in Child-Pugh Class A patients. Caution is needed in Class B patients. Should better be avoided in Class C patients
DapagliflozinSafe in Child-Pugh Class A patients. Caution is needed in Class B patients. Should better be avoided in Class C patients
EmpagliflozinSafe in Child-Pugh Class A patients. Caution is needed in Class B patients. Should better be avoided in Class C patients
InsulinSafe in use
Sulfonylureas

Liver is the major site of biotransformation for sulfonylureas. Sulfonylureas are metabolized into active and inactive metabolites in the liver through hepatic oxidative enzymes (CYP P450s). Then, they are extensively bound to serum proteins and excreted through renal pathway. Therefore, protein binding of sulfonylureas may be reduced in patients with T2DM and CLD due to hypoalbuminemia resulting to increased drug plasma concentrations[23-25] Therefore, sulfonylurea therapy in patients with CLD and renal failure increases the risk for hypoglycemia[26] that is more pronounced in the presence of malnutrition, a common comorbidity in CLD patients[7], and diminished gluconeogenic capacity[27]. Furthermore, in patients with alcoholic liver disease alcohol-induced enzyme degradation of sulfonylureas decreases drug’s effectiveness and further increases the risk of hypoglycemia[26].

There are only a few studies examined the effect of CLD on sulfonylurea metabolism. A study examined the effect of glipizide on hepatic uptake of insulin, showed that glipizide caused an increase in the estimated uptake of insulin in T2DM patients with cirrhosis, whereas a small decrease was observed in the control group[28].

Sulfonylureas therapy in patients with HI may be challenging since they are metabolized by the liver and excreted by the kidneys not only the parent drug but it’s active metabolites as well. Glimepiride and gliclazide are contraindicated in severe HI[23-25]. According to the position statement of the ADA and EASD insulin secretagogues should be avoided in severe HI due to the risk of hypoglycemia[15] (Table 1).

Meglitinides (glinides)

Glinides (nateglinide and repaglinide) have shorter half-lives than sulfonylureas and they do not have significant renal excretion[29,30]. They are extensively bound to serum albumin protein and are metabolized by oxidative biotransformation (CYP 450) and conjugation with glucuronic acid in the liver[31,32]. Repaglinide’s metabolism is mainly affected by the presence of CLD while this is not the case for nateglinide.One possible explanation for this discrepancy is that repaglinide is metabolized by CYP isoform 2C8[33] and nateglinide by CYP isoform2C9[30].

Repaglinide clearance is significantly reduced in patients with HI and should be used with caution while in T2DM patients with severe HI the drug is contraindicated[34]. On the other hand, nateglinide pharmacokinetics (PK) is not affected in patients with HI and, therefore, no adjustment of nateglinide dosage is needed in patients with mild to moderate HI[35], There are no data available in patients with severe HI (Table 1).

Alpha-glucosidase inhibitors (Acarbose)

Acarbose acts locally within the gastrointestinal tract by inhibiting enzymes (glycoside hydrolases) needed to digest carbohydrates[36]. The lack of intestinal absorption and hepatic metabolism, makes acarbose a safe choice in CLD patients with a good tolerability and absence of toxic effects[38], well-compensated non-alcoholic cirrhosis[39], and low-grade hepatic encephalopathy[40]. However, there may be a possibility of hyperammonemia when acarbose is prescribed to T2DM patients with advanced HI[37]. The effect of acarbose in hepatic encephalopathy was studied in 107 cirrhotic patients with T2DM. Acarbose therapy was related with decreased ammonia blood levels. However, no change in biochemical parameters of liver function was observed at the end of the study[40]. The findings of another study with the use of acarbose showed that T2DM associated with HI might be safely and effectively treated with acarbose except for a small increase in ammonia blood levels. Therefore, acarbose treatment in T2DM patients with cirrhosis might increase the risk ofhyperammonemia[37]. According to the position statement of the ADA acarbose is safe, useful, and well tolerated in CLD patients[15,16] (Table 1).

Thiazolidinediones

Pioglitazone: Pioglitazone is the only drug available in the market of this class; it is extensively metabolized by hydroxylation and oxidation and it is metabolized mainly by CYP2C8[41]. It is excreted primarily as metabolites and their conjugates in bile and feces[41]. Hepatic safety of pioglitazone was evaluated in a large observational study in T2DM patients in Japan where no case of HI was reported and no alanine aminotransferase (ALT) abnormalities with pioglitazone therapy in different dosages[42].

In a study, where the hepatic safety profile of pioglitazone (compared to glibenclamide) was examined in pioglitazone-treated patients, there was no case of hepatocellular injury in the pioglitazone group while and four cases were observed in the glibenclamide group. No case of hepatic dysfunction or HI was reported in the pioglitazone group[43]. However, in another study, the case-fatality rate of liver failure associated with rosiglitazone or pioglitazone was 81%, while only 14% of the patients recovered[44]. On the contrary, a large-scale study in Japan, in 24993 patients (28008 patient-years), no case of HI was found[42]. The above finding was confirmed in a retrospective data analysis of 1.12 patients with T2DM, where pioglitazone therapy was not associated with increased risk of HI or hepatitis compared to other OADs[45].

According to the position statement of the ADA in case of chirrosis or serum ALT level exceeding 2.5 times of upper normal limit (ULN), pioglitazone should be avoided[15]. Pioglitazone should be used with caution in CLD patients. It should be avoided in patients whose liver enzymes are > 3 times ULN range. Pioglitazone may be used in Child-Pugh Class A patients. However, it should be avoided in Class B and C patients[15] (Table 1).

DPP-4 inhibitors

Dipeptidyl peptidase-4 (DPP-4) inhibitors (sitagliptin, vildagliptin, saxagliptin, alogliptin and linagliptin) belong to the incretin-based glucose-lowering agents[46]. Sitagliptin is primarily excreted by the kidney and only a small percentage of the drug undergoes hepatic metabolism (mainly through the CYP3A4 isoenzyme and less through CYP2C8 isoenzyme)[47]. Vildagliptin is metabolized via hydrolysis and its inactive metabolites show renal excretion[47]. Saxagliptin is metabolized in vivo to form an active metabolite, and both parent drug and metabolite are excreted primarily via the kidneys[48]. Saxagliptin is primarily metabolized by CYP3A4 and CYP3A5 isoforms and eliminated through renal and hepatic routes. Alogliptin is metabolized into M-I, an N-demethylated active metabolite via CYP2D6, and M-II, an N-acetylated inactive metabolite and it is excreted primarily via the kidneys[48,49]. In contrast to other DPP-4 inhibitors, approximately 80% of administered dose of linagliptin[50] is eliminated through enterohepatic recycling[48].

The safety of DPP-4 inhibitors in T2DM patients was examined in a systematic review and meta-analysis, whereas no adverse events of hepatotoxiticy were reported[51]. Regarding sitagliptin, a few cases of drug-induced hepatic injury[52] and of elevated hepatic enzymes[53] have been reported. However, the causal pathogenetic relationship is still unclear[54]. Despite the initial concern about a possible hepatotoxicity of vildagliptin a pooled analysis of 38 controlled trials showed that there in not any significant increase of liver enzymes with vildagliptin therapy[55]. The safety of vildagliptin was confirmed in another pooled analysis in clinical trials with duration more than two years[56]. Sitagliptin PK is not affected by moderate HI[57]. Similarly, vildagliptin PK is not affected in patients with mild, moderate or even severe HI[58].

According to the already conducted studies, there is no liver safety issues for saxagliptin[59]. In the placebo-controlled SAVOR-TIMI 53 cardiovascular outcome trial, no signal of liver toxicity was found in the saxagliptin group[60]. Saxagliptin PK is affected only in a small degree in patients with HI[61,62].

A meta-analysis of 8 placebo-controlled trials confirmed the hepatic safety of linagliptin[63]. In a study in patients with mild and moderate HI, linagliptin was well tolerated without any adverse events[64]. There is only one case report described a probable linagliptin-induced liver toxicity[65]. One study[64] reported that mild, moderate or severe HI did not affect linagliptin PK compared to normal hepatic function.

According to the already conducted studies, there is no concern for hepatoxicity for alogliptin[66]. The large cardiovascular outcome study EXAMINE showed no signal of hepatotoxicity in the alogliptin group[67]. There is only one observational study coming from Japan where hypoglycemic symptoms under alogliptin therapy were reported and associated with liver disease and alcohol consumption[68]. Finally, in patients with moderate HI alogliptin PK is not affected[69].

Summary of product characteristic of sitagliptin, saxagliptin, and linagliptin recommends no dosage adjustments in patients with CLD[70-72], while vildagliptin should not be used in patients with CLD, including patients with

ALT or aspartate aminotransferase (AST) > 3x the ULN[73]. Therefore, DPP-4 inhibitors may be used in Child-Pugh Class A patients while their use requires caution in Class B patients. On the contrary, DPP-4 inhibitors are not preferred in Class C patients (Table 1).

GLP-1 receptor agonists

Glucagon-like peptide-1 receptor agonists (GLP-1RA) (exenatide, liraglutide, lixisenatide and dulaglutide) belong to the incretin-based glucose-lowering agents and offer new opportunities for the management of T2DM[15]. Renal excretion is the main pathway for the elimination of exenatide. Liraglutide and dulaglutide are metabolized into their component amino acids by general protein catabolism pathways[74-76].

The existing literature data regarding the effect of GLP-1RAs therapy in patients with CLD is limited. Therefore, until nowadays, clinical experience with liraglutide, exenatide and lixisenatide in CLD patients is limited. However, since exenatide is primarly excreted by the kidney, blood concentrations of the drug are not affected in patients with HI[77]. Regarding liraglutide it seems that drug concentrations are not affected by HI[78].

According to the SPC of exenatide and lixisenatide no dosage adjustment is required regarding their administration to patients with HI, whereas for liraglutide the therapeutic experience in patients with CLD is limited. On the basis of available evidence, GLP-1RAs should be used with caution without dose modification in CLD patients. Drugs of this class can be administered to Child-Pugh Class A patients. However, GLP-1RAs should be avoided in Class B and C patients (Table 1).

SGLT-2 inhibitors

Sodium-glucose co-transporter-2 (SGLT-2) inhibitors (canagliflozin, dapagliflozin, and empagliflozin) is a new class of antidiabetic agents acting through the inhibition of glucose reuptake in the kidney[79]. They undergo hepatic metabolism through glucuronidation, and small proportions of the parent drug are eliminated through renal route[79].

The safety of empagliflozin in patients with HI has been confirmed in a study investigating the effect of various degrees of HI on the PK of empagliflozin. In patients with HI empagliflozin PK was affected in a very small degree and, therefore, no dose adjustment of the drug is required in patients with HI[80]. The same pattern was observed in a canagliflozin trial, where the canagliflozin PK was not affected by the presence of mild or moderate HI. Therefore, no dose adjustment of canagliflozin is required for these patients[81]. Finally, a study on the PK and safety profile of dapagliflozin in patients with HI showed that systemic exposure to dapagliflozin was correlated with the degree of HI[82]. Therefore, dapagliflozin should be used with caution in these patients.

On the basis of available evidence, SGLT-2 inhibitors can be used with caution and lower doses should be considered during initiation of therapy in CLD patients. These agents are contraindicated in severe HI. The risk of dehydration and hypotension is associated with the use SGLT-2 inhibitors; hence, caution is required. Precisely, SGLT-2 inhibitors are safe in Child-Pugh Class A patients; however, they should be used with caution in Class B patients. Agents of this class should better be avoided in Class C patients (Table 1).

Insulin therapy

Liver is the major site of insulin metabolism. Almost half of the insulin produced by the pancreas is metabolized by the liver[83]. Hyperinsulinemia is a common finding in T2DM patients with cirrhosis, due to higher insulin secretion rate and reduced hepatic clearance. However, insulin requirement may vary in patients with CLD as a result of the reduced capacity for gluconeogenesis and hepatic breakdown of insulin. Therefore, daily dose requirements of exogenous administrated insulin can vary in a high degree and, therefore, is difficult to control blood glucose levels in these patients[7,16].

Insulin therapy is the safest and most effective therapy in patients with CLD. However, there is still the limitation of the increased risk of hypoglycemia[84]. Newer insulin analogs are preferred in CLD patients as their PK is unaltered and possesses low risk of hypoglycemia. However, it is suggested that frequent glucose monitoring and dose adjustments are required to minimize the risk of hypoglycemia or hyperglycemia in these patients[85-88]. The ADA guidelines highlight the importance of insulin therapy and suggest frequent dose adjustment and careful glucose monitoring in T2DM patients with CLD[15] (Table 1).

CONCLUSION

Management of T2DM in patients with CLD is still a challenge for the clinician. Most of the antidiabetic agents are either contradicted or need dosage titration due to alterations to their pharmacokinetics in patients with CLD. Insulin therapy seems to be the safest choice in patients with CLD. The existing literature data regarding the management of T2DM in patients with CLD are limited[89] and only small studies and meta-analyses exist showing the effect of CLD on PK of the OADs. However, the need for the development of guidelines for the management of T2DM in patients with CLD is growing following the high prevalence of HI that characterizes T2DM.

Footnotes

Manuscript source: Unsolicited manuscript

Specialty type: Medicine, Research and Experimental

Country of origin: Greece

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References
1.  Picardi A, D'Avola D, Gentilucci UV, Galati G, Fiori E, Spataro S, Afeltra A. Diabetes in chronic liver disease: from old concepts to new evidence. Diabetes Metab Res Rev. 2006;22:274-283.  [PubMed]  [DOI]
2.  Loria P, Lonardo A, Anania F. Liver and diabetes. A vicious circle. Hepatol Res. 2013;43:51-64.  [PubMed]  [DOI]
3.  Tolman KG, Fonseca V, Dalpiaz A, Tan MH. Spectrum of liver disease in type 2 diabetes and management of patients with diabetes and liver disease. Diabetes Care. 2007;30:734-743.  [PubMed]  [DOI]
4.  García-Compean D, Jaquez-Quintana JO, Maldonado-Garza H. Hepatogenous diabetes. Current views of an ancient problem. Ann Hepatol. 2009;8:13-20.  [PubMed]  [DOI]
5.  Kawaguchi T, Taniguchi E, Itou M, Sakata M, Sumie S, Sata M. Insulin resistance and chronic liver disease. World J Hepatol. 2011;3:99-107.  [PubMed]  [DOI]
6.  Blendea MC, Thompson MJ, Malkani S. Diabetes and chronic liver disease: Etiology and pitfalls in monitoring. Clin Diabetes. 2010;28:139.  [PubMed]  [DOI]
7.  Scheen AJ. Pharmacokinetic and toxicological considerations for the treatment of diabetes in patients with liver disease. Expert Opin Drug Metab Toxicol. 2014;10:839-857.  [PubMed]  [DOI]
8.  Khan R, Foster GR, Chowdhury TA. Managing diabetes in patients with chronic liver disease. Postgrad Med. 2012;124:130-137.  [PubMed]  [DOI]
9.  Slack A, Yeoman A, Wendon J. Renal dysfunction in chronic liver disease. Crit Care. 2010;14:214.  [PubMed]  [DOI]
10.  Butt S, Ahmed P, Liaqat P, Ahmad H. A study of malnutrition among chronic liver disease patients. Pak J Nutr. 2009;8:1465-1471.  [PubMed]  [DOI]
11.  Purnak T, Yilmaz Y. Liver disease and malnutrition. Best Pract Res Clin Gastroenterol. 2013;27:619-629.  [PubMed]  [DOI]
12.  Rodighiero V. Effects of liver disease on pharmacokinetics. An update. Clin Pharmacokinet. 1999;37:399-431.  [PubMed]  [DOI]
13.  Mobarhan S. The role of albumin in nutritional support. J Am Coll Nutr. 1988;7:445-452.  [PubMed]  [DOI]
14.  Albers I, Hartmann H, Bircher J, Creutzfeldt W. Superiority of the Child-Pugh classification to quantitative liver function tests for assessing prognosis of liver cirrhosis. Scand J Gastroenterol. 1989;24:269-276.  [PubMed]  [DOI]
15.  Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, Matthews DR; American Diabetes Association (ADA); European Association for the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35:1364-1379.  [PubMed]  [DOI]
16.  Hamed AE, Elsahar M, Elwan NM, El-Nakeep S, Naguib M, Soliman HH, Ahmed Aboubakr A, AbdelMaqsod A, Sedrak H, Assaad SN, Elwakil R, Esmat G, Salh S, Mostafa T, Mogawer S, Sadek SE, Saber MM, Ezelarab H, Mahmoud AA, Sultan S, El Kassas M, Kamal E, ElSayed NM, Moussa S. Managing diabetes and liver disease association. Arab J Gastroenterol. 2018;19:166-179.  [PubMed]  [DOI]
17.  Ahya SN, José Soler M, Levitsky J, Batlle D. Acid-base and potassium disorders in liver disease. Semin Nephrol. 2006;26:466-470.  [PubMed]  [DOI]
18.  DeFronzo R, Fleming GA, Chen K, Bicsak TA. Metformin-associated lactic acidosis: Current perspectives on causes and risk. Metabolism. 2016;65:20-29.  [PubMed]  [DOI]
19.  Deemer KS, Alvarez GF. A Rare Case of Persistent Lactic Acidosis in the ICU: Glycogenic Hepatopathy and Mauriac Syndrome. Case Rep Crit Care. 2016;2016:6072909.  [PubMed]  [DOI]
20.  Ampuero J, Ranchal I, Nuñez D, Díaz-Herrero Mdel M, Maraver M, del Campo JA, Rojas Á, Camacho I, Figueruela B, Bautista JD, Trinchet JD, Romero-Gómez M. Metformin inhibits glutaminase activity and protects against hepatic encephalopathy. PLoS One. 2012;7:e49279.  [PubMed]  [DOI]
21.  Nkontchou G, Cosson E, Aout M, Mahmoudi A, Bourcier V, Charif I, Ganne-Carrie N, Grando-Lemaire V, Vicaut E, Trinchet JC, Beaugrand M. Impact of metformin on the prognosis of cirrhosis induced by viral hepatitis C in diabetic patients. J Clin Endocrinol Metab. 2011;96:2601-2608.  [PubMed]  [DOI]
22.  Zhang X, Harmsen WS, Mettler TA, Kim WR, Roberts RO, Therneau TM, Roberts LR, Chaiteerakij R. Continuation of metformin use after a diagnosis of cirrhosis significantly improves survival of patients with diabetes. Hepatology. 2014;60:2008-2016.  [PubMed]  [DOI]
23.  Gliclazide Tablets. Prescribing Information. Whiddon Valley, Barnstaple: Actavis UK Ltd.  Available from: http://www.medicines.org.uk/emc/medicine/24126/SPC/Gliclazide + Tablets + BP + 80mg.  [PubMed]  [DOI]
24.  Glucotrol (Glipizide) Tablet. Bridgewater, NJ: Sanofi; October, 2013.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020496s027lbl.pdf.  [PubMed]  [DOI]
25.  Amaryl (Glimepiride) Tablet, . Prescribing Information. New York: Pfizer Inc.; October, 2013..  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/017783s025lbl.pdf.  [PubMed]  [DOI]
26.  Kalra S, Aamir AH, Raza A, Das AK, Azad Khan AK, Shrestha D, Qureshi MF, Md Fariduddin, Pathan MF, Jawad F, Bhattarai J, Tandon N, Somasundaram N, Katulanda P, Sahay R, Dhungel S, Bajaj S, Chowdhury S, Ghosh S, Madhu SV, Ahmed T, Bulughapitiya U, Qureshi MF, Md Fariduddin, Pathan MF, Jawad F. Place of sulfonylureas in the management of type 2 diabetes mellitus in South Asia: A consensus statement. Indian J Endocrinol Metab. 2015;19:577-596.  [PubMed]  [DOI]
27.  Diaßeta (Glyburide) Tablet. Prescribing Information. Bridgewater, NJ: Sanofi; October, 2013.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/017532Orig1s034lbl.pdf.  [PubMed]  [DOI]
28.  Nygren A, Bulow G, Sundblad L, Thunberg E, Wiechel KL. The effect of glipizide on extraction of insulin by the human cirrhotic and noncirrhotic liver. Metabolism. 1988;37:810-814.  [PubMed]  [DOI]
29.  Scott LJ. Repaglinide: a review of its use in type 2 diabetes mellitus. Drugs. 2012;72:249-272.  [PubMed]  [DOI]
30.  McLeod JF. Clinical pharmacokinetics of nateglinide: a rapidly-absorbed, short-acting insulinotropic agent. Clin Pharmacokinet. 2004;43:97-120.  [PubMed]  [DOI]
31.  Prandin (Repaglinide) Tablet. Prescribing Information. Princeton, NJ: Novo Nordisk Inc.; March, 2012..  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020741s040lbl.pdf.  [PubMed]  [DOI]
32.  Nateglinide Tablet. Prescribing Information. Spring Valley, NY: Par Pharmaceutical Companies, Inc.; June, 2009..  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/077463s000lbl. pdf.  [PubMed]  [DOI]
33.  Kalliokoski A, Backman JT, Neuvonen PJ, Niemi M. Effects of the SLCO1B1*1B haplotype on the pharmacokinetics and pharmacodynamics of repaglinide and nateglinide. Pharmacogenet Genomics. 2008;18:937-942.  [PubMed]  [DOI]
34.  Hatorp V, Walther KH, Christensen MS, Haug-Pihale G. Single-dose pharmacokinetics of repaglinide in subjects with chronic liver disease. J Clin Pharmacol. 2000;40:142-152.  [PubMed]  [DOI]
35.  Choudhury S, Hirschberg Y, Filipek R, Lasseter K, McLeod JF. Single-dose pharmacokinetics of nateglinide in subjects with hepatic cirrhosis. J Clin Pharmacol. 2000;40:634-640.  [PubMed]  [DOI]
36.  Balfour JA, McTavish D. Acarbose. An update of its pharmacology and therapeutic use in diabetes mellitus. Drugs. 1993;46:1025-1054.  [PubMed]  [DOI]
37.  Kihara Y, Ogami Y, Tabaru A, Unoki H, Otsuki M. Safe and effective treatment of diabetes mellitus associated with chronic liver diseases with an alpha-glucosidase inhibitor, acarbose. J Gastroenterol. 1997;32:777-782.  [PubMed]  [DOI]
38.  Zillikens MC, Swart GR, van den Berg JW, Wilson JH. Effects of the glucosidase inhibitor acarbose in patients with liver cirrhosis. Aliment Pharmacol Ther. 1989;3:453-459.  [PubMed]  [DOI]
39.  Gentile S, Turco S, Guarino G, Oliviero B, Annunziata S, Cozzolino D, Sasso FC, Turco A, Salvatore T, Torella R. Effect of treatment with acarbose and insulin in patients with non-insulin-dependent diabetes mellitus associated with non-alcoholic liver cirrhosis. Diabetes Obes Metab. 2001;3:33-40.  [PubMed]  [DOI]
40.  Gentile S, Guarino G, Romano M, Alagia IA, Fierro M, Annunziata S, Magliano PL, Gravina AG, Torella R. A randomized controlled trial of acarbose in hepatic encephalopathy. Clin Gastroenterol Hepatol. 2005;3:184-191.  [PubMed]  [DOI]
41.  Jaakkola T, Laitila J, Neuvonen PJ, Backman JT. Pioglitazone is metabolised by CYP2C8 and CYP3A4 in vitro: potential for interactions with CYP2C8 inhibitors. Basic Clin Pharmacol Toxicol. 2006;99:44-51.  [PubMed]  [DOI]
42.  Kawamori R, Kadowaki T, Onji M, Seino Y, Akanuma Y; PRACTICAL Study Group. Hepatic safety profile and glycemic control of pioglitazone in more than 20,000 patients with type 2 diabetes mellitus: postmarketing surveillance study in Japan. Diabetes Res Clin Pract. 2007;76:229-235.  [PubMed]  [DOI]
43.  Tolman KG, Freston JW, Kupfer S, Perez A. Liver safety in patients with type 2 diabetes treated with pioglitazone: results from a 3-year, randomized, comparator-controlled study in the US. Drug Saf. 2009;32:787-800.  [PubMed]  [DOI]
44.  Floyd JS, Barbehenn E, Lurie P, Wolfe SM. Case series of liver failure associated with rosiglitazone and pioglitazone. Pharmacoepidemiol Drug Saf. 2009;18:1238-1243.  [PubMed]  [DOI]
45.  Rajagopalan R, Iyer S, Perez A. Comparison of pioglitazone with other antidiabetic drugs for associated incidence of liver failure: no evidence of increased risk of liver failure with pioglitazone. Diabetes Obes Metab. 2005;7:161-169.  [PubMed]  [DOI]
46.  Scheen AJ. A review of gliptins in 2011. Expert Opin Pharmacother. 2012;13:81-99.  [PubMed]  [DOI]
47.  Vincent SH, Reed JR, Bergman AJ, Elmore CS, Zhu B, Xu S, Ebel D, Larson P, Zeng W, Chen L, Dilzer S, Lasseter K, Gottesdiener K, Wagner JA, Herman GA. Metabolism and excretion of the dipeptidyl peptidase 4 inhibitor [14C]sitagliptin in humans. Drug Metab Dispos. 2007;35:533-538.  [PubMed]  [DOI]
48.  Golightly LK, Drayna CC, McDermott MT. Comparative clinical pharmacokinetics of dipeptidyl peptidase-4 inhibitors. Clin Pharmacokinet. 2012;51:501-514.  [PubMed]  [DOI]
49.  Scheen AJ. Pharmacokinetics of dipeptidylpeptidase-4 inhibitors. Diabetes Obes Metab. 2010;12:648-658.  [PubMed]  [DOI]
50.  Scheen AJ. Linagliptin for the treatment of type 2 diabetes (pharmacokinetic evaluation). Expert Opin Drug Metab Toxicol. 2011;7:1561-1576.  [PubMed]  [DOI]
51.  Gooßen K, Gräber S. Longer term safety of dipeptidyl peptidase-4 inhibitors in patients with type 2 diabetes mellitus: systematic review and meta-analysis. Diabetes Obes Metab. 2012;14:1061-1072.  [PubMed]  [DOI]
52.  Toyoda-Akui M, Yokomori H, Kaneko F, Shimizu Y, Takeuchi H, Tahara K, Motoori T, Ohbu M, Oda M, Hibi T. A case of drug-induced hepatic injury associated with sitagliptin. Intern Med. 2011;50:1015-1020.  [PubMed]  [DOI]
53.  Gross BN, Cross LB, Foard J, Wood Y. Elevated hepatic enzymes potentially associated with sitagliptin. Ann Pharmacother. 2010;44:394-395.  [PubMed]  [DOI]
54.  Navarro VJ, Senior JR. Drug-related hepatotoxicity. N Engl J Med. 2006;354:731-739.  [PubMed]  [DOI]
55.  Ligueros-Saylan M, Foley JE, Schweizer A, Couturier A, Kothny W. An assessment of adverse effects of vildagliptin versus comparators on the liver, the pancreas, the immune system, the skin and in patients with impaired renal function from a large pooled database of Phase II and III clinical trials. Diabetes Obes Metab. 2010;12:495-509.  [PubMed]  [DOI]
56.  Schweizer A, Dejager S, Foley JE, Kothny W. Assessing the general safety and tolerability of vildagliptin: value of pooled analyses from a large safety database versus evaluation of individual studies. Vasc Health Risk Manag. 2011;7:49-57.  [PubMed]  [DOI]
57.  Migoya EM, Stevens CH, Bergman AJ, Luo WL, Lasseter KC, Dilzer SC, Davies MJ, Wagner JA, Herman GA. Effect of moderate hepatic insufficiency on the pharmacokinetics of sitagliptin. Can J Clin Pharmacol. 2009;16:e165-e170.  [PubMed]  [DOI]
58.  He YL, Sabo R, Campestrini J, Wang Y, Ligueros-Saylan M, Lasseter KC, Dilzer SC, Howard D, Dole WP. The influence of hepatic impairment on the pharmacokinetics of the dipeptidyl peptidase IV (DPP-4) inhibitor vildagliptin. Eur J Clin Pharmacol. 2007;63:677-686.  [PubMed]  [DOI]
59.  Ali S, Fonseca V. Saxagliptin overview: special focus on safety and adverse effects. Expert Opin Drug Saf. 2013;12:103-109.  [PubMed]  [DOI]
60.  Scirica BM, Bhatt DL, Braunwald E, Steg PG, Davidson J, Hirshberg B, Ohman P, Frederich R, Wiviott SD, Hoffman EB, Cavender MA, Udell JA, Desai NR, Mosenzon O, McGuire DK, Ray KK, Leiter LA, Raz I; SAVOR-TIMI 53 Steering Committee and Investigators. Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. N Engl J Med. 2013;369:1317-1326.  [PubMed]  [DOI]
61.  Boulton DW, Li L, Frevert EU, Tang A, Castaneda L, Vachharajani NN, Kornhauser DM, Patel CG. Influence of renal or hepatic impairment on the pharmacokinetics of saxagliptin. Clin Pharmacokinet. 2011;50:253-265.  [PubMed]  [DOI]
62.  Patel C, Castaneda L, Frevert U, Li L, Kornhauser DM, Boulton DW. Single-dose pharmacokinetics and safety of saxagliptin in subjects with hepatic impairment compared with healthy subjects (Abstract 537-P). Diabetes. 2008;57:A160.  [PubMed]  [DOI]
63.  Schernthaner G, Barnett AH, Emser A, Patel S, Troost J, Woerle HJ, von Eynatten M. Safety and tolerability of linagliptin: a pooled analysis of data from randomized controlled trials in 3572 patients with type 2 diabetes mellitus. Diabetes Obes Metab. 2012;14:470-478.  [PubMed]  [DOI]
64.  Graefe-Mody U, Rose P, Retlich S, Ring A, Waldhauser L, Cinca R, Woerle HJ. Pharmacokinetics of linagliptin in subjects with hepatic impairment. Br J Clin Pharmacol. 2012;74:75-85.  [PubMed]  [DOI]
65.  Kutoh E. Probable linagliptin-induced liver toxicity: a case report. Diabetes Metab. 2014;40:82-84.  [PubMed]  [DOI]
66.  Scott LJ. Alogliptin: a review of its use in the management of type 2 diabetes mellitus. Drugs. 2010;70:2051-2072.  [PubMed]  [DOI]
67.  White WB, Cannon CP, Heller SR, Nissen SE, Bergenstal RM, Bakris GL, Perez AT, Fleck PR, Mehta CR, Kupfer S, Wilson C, Cushman WC, Zannad F; EXAMINE Investigators. Alogliptin after acute coronary syndrome in patients with type 2 diabetes. N Engl J Med. 2013;369:1327-1335.  [PubMed]  [DOI]
68.  Kajiwara A, Saruwatari J, Sakata M, Morita K, Kita A, Oniki K, Yamamura M, Murase M, Koda H, Hirota S, Ishizuka T, Nakagawa K. Risk factors for adverse symptoms during dipeptidyl peptidase-IV inhibitor therapy: a questionnaire-based study carried out by the Japan Pharmaceutical Association Drug Event Monitoring project in Kumamoto Prefecture. Drug Saf. 2013;36:981-987.  [PubMed]  [DOI]
69.  Karim A, Fleck P, Dorsey D. Single-dose pharmacokinetics of alogliptin benzoate (SYR-322), a highly selective dipeptidyl peptidase-4 inhibitor, in subjects with moderate hepatic impairment (Abstract). J Clin Pharmacol. 2007;47:Abstract 107.  [PubMed]  [DOI]
70.  JANUVIA® (Sitagliptin) Tablets. Prescribing Information. Whitehouse Station, NJ: Merc and Co., Inc.; August, 2015.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/021995s034lbl. pdf.  [PubMed]  [DOI]
71.  Onglyza (Saxagliptin) Tablets. Prescribing Information. Wilmington, DE: AstraZeneca Pharmaceuticals LP; April, 2016.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/022350s014lbl. pdf.  [PubMed]  [DOI]
72.  Tradjenta® (Linagliptin) Tablets. Prescribing Information, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; August, 2015.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/201280s012lbl.pdf.  [PubMed]  [DOI]
73.  Galvus (Vildagliptin) Tablets. Prescribing Information, Novartis Pharmaceuticals UK Ltd; December, 2015.  Available from: http://www.medicines.org.uk/emc/medicine/20734.  [PubMed]  [DOI]
74.  Bydureon (Exenatide Extendedrelease) Injectable Suspension. Prescribing Information. Wilmington, DE: AstraZeneca Pharmaceuticals LP; September, 2015.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/022200s015s016s017s018lbl.pdf.  [PubMed]  [DOI]
75.  Victoza (Liraglutide) Injection. Prescribing Information. Bagsvaerd, Denmark: Novo Nordisk A/S; April, 2016.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/022341s025lbl. pdf.  [PubMed]  [DOI]
76.  Trulicity (Dulaglutide) Injection. Prescribing Information. Indianapolis, IN: Eli Lilly and Company; September, 2014.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/nda/2014/125469Orig1s000Lbl.pdf.  [PubMed]  [DOI]
77.  Exenatide Summary of Product Characteristics.  Available from: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000698/WC500051845.pdf.  [PubMed]  [DOI]
78.  Flint A, Nazzal K, Jagielski P, Hindsberger C, Zdravkovic M. Influence of hepatic impairment on pharmacokinetics of the human GLP-1 analogue, liraglutide. Br J Clin Pharmacol. 2010;70:807-814.  [PubMed]  [DOI]
79.  Scheen AJ. Pharmacokinetics, Pharmacodynamics and Clinical Use of SGLT2 Inhibitors in Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease. Clin Pharmacokinet. 2015;54:691-708.  [PubMed]  [DOI]
80.  Macha S, Rose P, Mattheus M, Cinca R, Pinnetti S, Broedl UC, Woerle HJ. Pharmacokinetics, safety and tolerability of empagliflozin, a sodium glucose cotransporter 2 inhibitor, in patients with hepatic impairment. Diabetes Obes Metab. 2014;16:118-123.  [PubMed]  [DOI]
81.  Devineni D, Curtin CR, Marbury TC, Smith W, Vaccaro N, Wexler D, Vandebosch A, Rusch S, Stieltjes H, Wajs E. Effect of hepatic or renal impairment on the pharmacokinetics of canagliflozin, a sodium glucose co-transporter 2 inhibitor. Clin Ther. 2015;37:610-628.e4.  [PubMed]  [DOI]
82.  Kasichayanula S, Liu X, Zhang W, Pfister M, LaCreta FP, Boulton DW. Influence of hepatic impairment on the pharmacokinetics and safety profile of dapagliflozin: an open-label, parallel-group, single-dose study. Clin Ther. 2011;33:1798-1808.  [PubMed]  [DOI]
83.  Iglesias P, Díez JJ. Insulin therapy in renal disease. Diabetes Obes Metab. 2008;10:811-823.  [PubMed]  [DOI]
84.  Mukhopadhyay J Use of Insulin in Chronic Liver Disorders. Medicine Update;. 2005; Available from: http://www.apiindia.org/pdf/medicine_update_2005/chapter_43.pdf.  [PubMed]  [DOI]
85.  Lantus (Insulin Glargine [rDNA origin]) Injection. Prescribing Information. Bridgewater, NJ: Sanofi; July, 2015.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/021081s063lbl.pdf.  [PubMed]  [DOI]
86.  Apidra (Insulin Glulisine [rDNA origin]) Injection. Prescribing Information. Bridgewater, NJ: Sanofi Aventis U.S. LLC; July, 2015.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/021629s030lbl.pdf.  [PubMed]  [DOI]
87.  NovoLog (Insulin Aspart [rDNA origin]) Injection. Prescribing Information. Princeton, NJ: Novo Nordisk; February, 2015.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/021172s064lbl.pdf.  [PubMed]  [DOI]
88.  Ryzodeg 70/30 (Insulin Degludec and Insulin Aspart) Injection. Prescribing Information. Bagsvaerd, Denmark: Novo Nordisk; 2019 May 15.  Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/203313lbl.pdf.  [PubMed]  [DOI]
89.  Gangopadhyay KK, Singh P. Consensus Statement on Dose Modifications of Antidiabetic Agents in Patients with Hepatic Impairment. Indian J Endocrinol Metab. 2017;21:341-354.  [PubMed]  [DOI]