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Hypoglycaemia in Cirrhosis — RACP Adult Medicine MCQ

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ModerateEndocrinology & DiabetesHypoglycaemia in CirrhosisRACP Adult Medicine

A 55-year-old man with type 2 diabetes on metformin and insulin develops recurrent episodes of hypoglycaemia despite reducing his insulin dose. His HbA1c is 51 mmol/mol. He has recently been diagnosed with chronic liver disease with cirrhosis. What is the mechanism of increased hypoglycaemia risk in cirrhosis?

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Correct answer: E — Metformin accumulation

The cirrhotic liver has markedly reduced capacity for gluconeogenesis and glycogen storage – two critical counter-regulatory mechanisms against hypoglycaemia. This means patients with cirrhosis are more susceptible to hypoglycaemia from insulin and sulfonylureas. HbA1c may also be falsely low in cirrhosis (due to shortened RBC lifespan from hypersplenism). Glucose targets should be relaxed (HbA1c 7–64 mmol/mol), insulin doses reduced, and sulfonylureas avoided. CGM may be helpful for monitoring.

Reference: eTG – 2025 – Endocrinology; ADS – 2024 – Diabetes in Liver Disease