Clinical Fellow Houston Methodist Hospital Houston, Texas, United States
Introduction : TIPS is an effective tool that helps reduce portal pressure by shunting portal blood to systemic circulation. Studies have shown hyperglycemia following the procedure necessitating higher doses of insulin in cirrhotic patients with overt diabetes mellitus (DM).The normal first-pass metabolism of insulin and glucagon is by-passed following TIPS resulting in hyperinsulinemia, hyperglucagonemia and increased insulin resistance. We present a case of severe insulin resistance after TIPS with an excellent response to initiation of glucagon-like peptide 1 (GLP-1)Â agonist for glycemic control.
Case(s) Description : A 50 year old man with decompensated alcoholic cirrhosis for 10 years presented for an elective TIPS procedure. His medical history included type 2 DM for 9 years managed with glargine and lispro with total daily dose of insulin (TDD) 175 units (1.4U/kg body weight), and class 3 obesity (BMI 44 kg/m2). Physical exam was significant for obesity and acanthosis nigricans. Labs revealed A1C of 10.9% with Hgb of 8.9 mg/dL. Preoperatively, patient received one dose of IV Dexamethasone 8mg for nausea prophylaxis. Post procedure, he was found to have elevated serum BG of 509 mg/dl, and was started on insulin infusion. Over the next 24 hours, his insulin requirements increased significantly to TDD 409 units (3.3U/kg) with 274 units from infusion and 135 units of subcutaneous prandial insulin. On subsequent days, his insulin requirements continued to increase and insulin glargine was added. On day 7, he was transitioned to Regular U500 subcutaneously. A glucagon level measured on day 7 was 894 pg/ml. On day 12, the patient was managed on U-500 120 units QAC and insulin glargine 100 units BID (TDD 560 units; 4.6u/kg). At this point liraglutide 0.6mg daily was added. On day 13, the patient’s insulin requirements decreased rapidly and by day 16, he was discharged on glargine 30 units bid, lispro 20 units QAC (TDD 120units;1u/kg) and liraglutide 0.6mg daily with a decreased glucagon level of 134 pg/mL.
Discussion : Cirrhotic patients with DM can exhibit a heterogeneous glycemic response to TIPS, potentially attributable to increased insulin resistance, variability in renal function, and reduced skeletal muscle mass. Our patient demonstrated significant hyperglucagonemia concordant with increased insulin requirements immediately following TIPS procedure. With the addition of a GLP-1 agonist, we observed a remarkable decline in glucagon levels along with insulin requirements, consistent with the mechanism of action of GLP-1 agonists. Further investigation is needed on the role of GLP-1 agonists post TIPS in patients with DM.
