Discontinuation of Basal and Bolus Insulin using a Combined Dietary and Pharmacologic Approach in a Patient with Type 2 Diabetes and NASH-Cirrhosis in the Primary Care Setting

Background:Currently, there are no FDA-approved pharmacologic treatments for NAFLD and lifestyle intervention remains first line. As patient adherence to dietary and exercise modification has limited success, NAFLD is currently the most rapidly increasing indication for liver transplant in Western countries. Further, NAFLD is considered an independent risk factor for both liver-related and all-cause mortality. Given that weight loss via dietary modifications is one of the few proven treatments for NAFLD, it is important to continue investigating the effectiveness of current dietary recommendations. Intermittent fasting (IF) has become an increasingly popular dietary regimen in the management of weight loss and metabolic disorders, including NAFLD. Time-restricted feeding (TRF) is a form of IF that allows intake of meals within a specific time frame, followed by periods of fasting. Fasting periods vary from 16 hours to several days and depend largely on patient tolerance and preference. This case report investigates the effectiveness of IF in a patient with severe NAFLD complicated by decompensated cirrhosis.Case Presentation: Patient is a 48-year-old male with past medical history of metabolic syndrome, meeting criteria with central obesity >40 in. circumference, HDL < 40, type 2 diabetes, and hypertension. He was admitted to the hospital for GI bleed in February 2021 with subsequent EGD showing ruptured esophageal varices. Further work up with abdominal CT showed fatty liver infiltrate with confirmed cirrhosis. Without history of excessive alcohol intake, use of hepatotoxic medications, or identifiable genetic causes, a diagnosis of NAFLD complicated by cirrhosis was made. At diagnosis, his weight was 303.2 lbs with BMI of 47.4. Medications included metformin 1000 mg BID, semaglutide 0.25 mg weekly, insulin glargine (U-300) 70 units daily, and insulin aspart 14 units TID plus sliding scale. Dietary interventions were discussed with patient and family in June 2021. Patient preferences, family adherence, access to food, and financial status were evaluated prior to initiation of dietary changes. After extensive dialogue, the following TRF regimen was implemented: ketogenic diet (carbohydrates < 30g/ day) with all food consumed within an 8-hour feeding window and one 36-hour fast per week. Medications were adjusted to reduce the risk of hypoglycemia. Patient was monitored closely via continuous glucose monitor throughout the intervention. After 3 weeks, the patient was able to discontinue his basal and bolus insulin and repeat imaging at week 8 showed resolution of NAFLD via MRI and a weight loss of > 10%. Conclusions: Medically supervised, therapeutic fasting regimens can help reverse hepatic steatosis in NAFLD. Intermittent fasting is a practical dietary intervention that can also increase insulin sensitivity and improve blood glucose control. Considering lifestyle interventions are the only treatment for NAFLD, more research is needed to determine effectiveness of current recommendations.