TABLE 5.

A decalogue with key messages for the treatment of diabetes in the setting of liver transplant

Key messages
• Support healthy diet and moderate physical activity through continuous counseling by dietitians and lifestyle trainers, according to liver disease cause and severity, timing to surgery, and comorbidities.
• Provide intensive programs of cognitive behavior therapy delivered by dedicated teams to support weight loss or limit the negative effects of sarcopenia in waitlisted patients with obesity, as well as to prevent unhealthy post-LTx weight gain.
• Define HbA1c target considering patients’ frailty and the risk of hypoglycemia and CV events, which significantly affect all-cause, CV, and renal outcomes. Consider that HbA1c might not reflect metabolic control in anemia or recent bleeding.
• Maintain tapered metformin administration in waitlisted patients, except for eGFR <30 mL/min (CKD stage ≥4). Scale up metformin or use slow-release formulations in PTDM to avoid GI symptoms and interactions with immunosuppressive drug absorption.
• Use GLP-1RAs and SGLT-2Is with confidence unless contraindicated by severe CKD.
• Consider the possible interaction of GLP-1RAs with β-blocking agents in the prevention of GI bleeding in cirrhosis. Check electrolytes and blood pressure in patients treated with SGLT-2Is and taper down Henle loop diuretics.
• Treat PTDM according to schedules as simple as possible, limiting polypharmacology to avoid drug–drug interactions and to favor adherence.
• Limit the use of insulin to the sole basal insulin as long as possible, both in waitlisted and in post-LTx patients, to reduce the risk of hypoglycemia and sustain quality of life. The association of basal insulin and GLP-1RAs may be a feasible alternative to intensified insulin treatment.
• Modulate immunosuppressive therapy, using steroid-free regimens with basiliximab induction or adding mycophenolate mofetil to mitigate the diabetogenic effects of calcineurin inhibitors (particularly tacrolimus). Do not use acarbose in the post-LTx phase to avoid diarrhea and malabsorption.
• Consider bariatric surgery to treat diabetes in selected cases, particularly in the post-LTx phase when associated with important weight gain.

CKD, chronic kidney disease; CV, cardiovascular; DM, diabetes mellitus; eGFR, estimated glomerular filtration rate; GI, gastrointestinal; GLP-1RA, glucagon-like peptide-1 receptor agonist; HbA1c, A1c glycated hemoglobin; LTx, liver transplantation; PTDM, posttransplantation diabetes mellitus; SGLT-2I, sodium-glucose cotransporter-2 inhibitor.