*EMBARGOED All research presented at the World Congress of Gastroenterology at ACG2017 is strictly embargoed until Monday, October 16, 2017, at 8:00 am EDT.
Poster 1411 The Best of Both Worlds: Impact of Remission of Hepatitis C on Glycemic Control in Patient with Type 2 Diabetes
Author Insight from Shradha Gupta, MD, St. Vincent Hospital
What’s new here and important for clinicians?
Chronic hepatitis C (CHC) is one of the major causes of chronic liver disease, cirrhosis and death from end-stage liver disease in the world. Although several studies have shown that CHC is strongly associated with metabolic derangements such as insulin resistance and diabetes mellitus, the mechanism of CHC-induced insulin resistance is not completely understood. Hepatitis C virus is thought to modulate gene expression to cause insulin insensitivity, thereby increasing the risk of type 2 diabetes mellitus (T2DM). Several mechanisms of CHC-induced insulin resistance are proposed including upregulation of inflammatory cytokine TNF-alpha, hypophosphorylation of insulin receptor substrate 1 and 2, phosphorylation of Akt, up-regulation of gluconeogenic genes, accumulation of lipids, and targeting lipid storage organelles.
Insulin resistance is shown to be negatively associated with a sustained virological response (SVR) to peg-interferon plus ribavirin-based anti-viral therapy. Very few studies have examined the effect of combining an insulin sensitizer such as metformin and thiazolidinedione to anti-HCV therapy. The effect of SVR to anti-HCV therapy on insulin resistance and glycemic control in patients with preexisting T2DM is largely unknown. In the last few years there have been major advances in the treatment of CHC, including availability of more-effective oral anti-viral therapy. More than 90% patients of CHC have a SVR in response to the new oral anti-viral agents.
We studied the effect of SVR achieved by the new oral-HCV therapy on glycemic control in patients with preexisting T2DM. The results revealed the mean HbA1C declined from 9.9% before treatment to 6.1% after SVR. Most patients required decrease in anti-diabetic treatment. Interestingly, decrease in A1c occurred without significant lifestyle or weight changes. Although not examined in our study, we believe that the effect on A1c following successful treatment of CHC is most likely caused by decrease in insulin resistance.
Thus, we recommend T2DM screening to be incorporated into management of CHC. Similarly, patients with high-risk behavior who have T2DM should be screened for CHC. This early diagnosis and treatment may well save lives.
What do patients need to know?
Hyperglycemia and diabetes mellitus may occur in all liver diseases, independent of etiology, especially at the advanced stage. The risk of diabetes mellitus increases in the presence of CHC infection, even in patients without cirrhosis. Several studies have shown that hyperglycemia and diabetes mellitus are about three-fold more prevalent in patients with chronic HCV infection. The treatment of hepatitis C viral infection has been revolutionized by the availability of the large number of oral anti-viral medications.
The new drugs are easier to administer and cause less-adverse reactions compared with previous drug therapy. Early recognition and treatment of hepatitis C may avoid major complications such as cancer, diabetes and even death. In addition, our study showed that successful treatment of hepatitis C remarkably improved blood glucose control in patients with pre-existing type 2 diabetes mellitus.
Shradha Gupta, MD, St. Vincent Hospital
George M. Abraham, MD, MPH, St. Vincent Hospital
Nitin Trivedi, MD, St. Vincent Hospital
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