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What do you need to know about NAFLD and NASH?
NAFLD (Non-Alcoholic Fatty Liver Disease) is a silent disease and it is incredibly common nowadays. It affects 28% of the global population, more than 60% of those with type 2 diabetes. There is a positive and reciprocal relationship between fatty liver disease and diabetes. And most importantly, fatty liver disease is a risk factor for cardiovascular disease, because it doubles that risk. Now we can say that fatty liver disease actually doubles a person's risk for cardiovascular disease.
Image represents Screening for advanced fibrosis
Who and How to Screen
Who is at high risk?
- All patients with type 2 diabetes should be screened
- Along with anyone who has two or more components of metabolic syndrome
- Patients with the incidental finding of steatosis on an imaging test, or elevated transaminases.
All three of these groups should be screened.
How to screen?
One of the first and most important things to do is a history and physical.
- Make sure there isn't excessive alcohol intake. We can then do a very simple, noninvasive, and inexpensive screening test that helps in determining whether the patient needs further evaluation.
- With a CBC, patient's age, and transaminase levels, you can calculate a FIB-4 score. It is available on many medical calculators, so it's easily accessed.
- If the FIB-4 score is < 1.3, the patient is at low risk for progression to advanced cirrhosis and fibrosis and probably does not need to be referred to another clinical team.
- Conversely, if the FIB-4 score is > 2.67, that patient is at very high risk for advancing to bridging fibrosis and cirrhosis. These patients should have a direct referral to hepatology. The FIB-4 easily differentiates who needs immediate specialty referral.
Fibroscan Test to check Liver Stiffness
Patients with FIB-4 scores between 1.3 and 2.6 are at indeterminate risk. To help sort them out, these patients need further testing with a liver stiffness measurement. We can then see whether there are structural changes in the liver. It used to be that everyone had to have a biopsy, but this allows us to send fewer patients for biopsy.
The FibroScan is one of the best ways to test for liver stiffness and it is widely available, although not everywhere. If you don't have access to the FibroScan, work with your gastroenterologist or hepatologist to get that testing done.
If liver stiffness is low, they fall back on the right side in the low-risk category. If high, they fall into indeterminate or high risk and probably need to have an evaluation by a specialist.
It's important to remember that many patients come through with elevated transaminases or with steatosis noted on imaging. Those patients may have fatty liver disease or they might have other conditions. Make sure you take a good history to ensure that they don't have excessive alcohol intake or a risk for or history of hepatitis B or C.
If indicated, consider the possibility of autoimmune or metabolic liver disease. If those things are not present and testing is negative, you go back to the original low-risk pathway. If those things are present and testing is positive, then you probably need referral to a Liver Specialist near you.
Finally, how do we treat it? I want to focus first on the things that apply to all three groups.
How do we treat it?
- Everyone should have lifestyle intervention focused on weight loss. Even small amounts of weight loss can have substantial benefits, not only in the progression of fatty liver disease but also for cardiovascular risk, which is the most common cause of death in people with fatty liver disease. So don't forget lifestyle intervention, including increased physical activity, structured weight loss programs, and if needed, weight loss medications or weight loss surgery.
- If the patient is at indeterminate risk, you may want to engage in a structured lifestyle program, cardiovascular risk reduction, and more intensive weight loss methods, including metabolic surgery.
- Patients with diabetes might have indications for certain medications. I want to highlight that nothing is FDA-approved to date for the treatment of NASH or NAFLD. But in studies, among people who don't have diabetes, vitamin E has been shown to be helpful. In patients with diabetes, pioglitazone and the GLP-1 receptor agonists (with most of the data reported on semaglutide) have been shown to help reduce progression in people at risk.
- For patients in the high-risk group, you will be working hand in hand with a hepatologist or gastroenterologist. Your role remains the same: focusing on lifestyle intervention. You may be prescribing additional pharmacotherapy for type 2 diabetes. In addition to standard of care for high-risk patients, there are a number of novel agents coming that will be helpful in the treatment of NASH, so getting your patients into hepatology treatment circles will give them access to the newest treatments.
We hope that this blog will help determine who you can manage in the primary care setting, who needs further fibroscan testing, and who should be seen immediately by a hepatologist.
Dr Chirayu Chokshi, Dr. Dhaval Dave, Dr. Jaydeep Patel & Dr. Darshak Shah together carry an experience of 27 years in this field & they have done more than 35000 endoscopy procedures.
Dr. Chirayu Chokshi & team is an expert in treating Non-Alcoholic Fatty Liver Disease in Vadodara, Gujarat. For more information, visit our website www.gastrovadodara.com or call us on 9081333897 / 9825795257 to book an appointment.