Approach to the Patient with Nonalcoholic Fatty Liver Disease (NAFLD)
The Journal of Clinical Endocrinology and Metabolism (JCEM): Published
On October, 2022
Nonalcoholic fatty liver disease
(NAFLD) is associated with obesity and type 2 diabetes (T2D), causing
substantial burden from hepatic and extrahepatic complications.
TAKE-HOME MESSAGE
This review discusses practical
approaches to the management of patients with NAFLD, with an emphasis on
cirrhosis prevention. Clinicians should calculate the FIB-4 index for patients
with NAFLD to assess the potential degree of liver fibrosis, as this may
dictate whether further imaging or biopsy is warranted.
Lifestyle modification remains the
mainstay in treatment, with an emphasis on following a Mediterranean diet,
weight loss, and limiting alcohol consumption. Pharmacotherapy to assist in
weight loss is recommended when diet and exercise alone are not enough.
This review highlights the use of
GLP-1 receptor agonists, specifically semaglutide, in patients with obesity and
non-alcoholic steatohepatitis as well as their use in patients after liver
transplantation with recurrence of NAFLD.
Lastly, the use of statins is
highly recommended, particularly in patients undergoing transplantation, as CVD
remains the leading cause of death in patients undergoing liver transplantation.
The management of patients with NAFLD requires a comprehensive approach, with an emphasis on lifestyle modification and weight loss as well as evidence to suggest a role for GLP-1 receptor agonists (Dulaglutide, Semaglutide, Liraglutide) in assisting with weight loss.
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CONTEXT
Nonalcoholic fatty liver disease
(NAFLD) is associated with obesity and type 2 diabetes (T2D), causing
substantial burden from hepatic and extrahepatic complications. However,
endocrinologists often follow people who are at the highest risk of its more
severe form with nonalcoholic steatohepatitis or NASH (i.e., metabolic
syndrome, prediabetes/T2D). Endocrinologists are in a unique position to
prevent cirrhosis in this population with early diagnosis and treatment.
OBJECTIVE
Offer endocrinologists a practical
approach for the management of patients with NAFLD, including diagnosis,
fibrosis risk-stratification and referral to hepatologists.
CASES
1) an asymptomatic patient with
obesity and cardiometabolic risk factors, found to have hepatic steatosis; 2) a
patient with T2D and NASH with clinically significant liver fibrosis; and 3) a
liver transplant recipient with a history of NASH cirrhosis, regaining weight
and with recurrent NAFLD on transplanted organ.
CONCLUSIONS
NASH is reversible with treatment
of obesity, calling for a broader use of structured weight-loss programs,
obesity pharmacotherapy and bariatric surgery. While no drugs are FDA-approved
for the treatment of NASH, diabetes medications such as pioglitazone and some
glucagon-like peptide 1 receptor agonists, improve liver histology and
cardiometabolic health. Sodium-glucose cotransporter-2 inhibitors and insulin
may ameliorate steatosis, but their effect on steatohepatitis and fibrosis
remains unclear. Awareness by endocrinologists about which are the high-risk groups,
establishing an early diagnosis of fibrosis (i.e., FIB-4, liver elastography),
long-term monitoring, and timely referral to the hepatologist within the care
of a multidisciplinary team are all critical to curve the looming epidemic of
cirrhosis from NAFLD upon us.
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