NAFLD & NASH Treatment in Primary Care: 8 Questions based on AASLD Guidance
Weight loss for patients with NAFLD is the key to improvement of histopathologic features. Find out what else you know about treatment of NAFLD/NASH with 8 guidance-based questions.
The American Association for the Study of Liver Diseases (AASLD) outlines a data‐supported approach to the treatment nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) in a guidance document published in Hepatology.
While disease-specific pharmacotherapy is still in clinical trials, there are a number of recommended approaches to management using existing medications and non-drug intervention. Find out what you know about these with the following 8 questions.
1. Pharmacologic treatments in the management of NAFLD aimed primarily at improving liver disease generally should be limited to those with which of the above?
Answer: D. Biopsy-proven NASH and fibrosis. NAFLD treatment should include liver disease and associated metabolic comorbidities. From a liver standpoint, patients who have NAFLD but not SH or any fibrosis have excellent prognosis.
2. Which component of lifestyle modification is the key to improvement in the histopathologic features of NASH?
Answer: A. Weight loss. Weight loss generally reduces hepatic steatosis by hypocaloric diet alone or in conjunction with increased physical activity. Weight loss of ≥3%-5% of body weight appears necessary to improve steatosis. Weight loss of 7%‐10% of body weight is needed to improve most histopathologic features of NASH, including fibrosis.
3. True or False: Metformin is recommended for treating NASH in adult patients.
Answer: B. False. In studies that investigated the effect of metformin on aminotransferases and liver histology in patients with NASH, metformin improved serum aminotransferases and insulin resistance but did not significantly improve liver histology. Two meta‐analyses concluded that metformin therapy does not improve liver histology in patients with NAFLD and NASH.
4. Pioglitazone improves liver histology in which patients with biopsy‐proven NASH?
Answer: C. Both. Pioglitazone may be used to treat patients with biopsy‐proven NASH who have T2D and those who do not. Risks and benefits should be discussed with patients before pioglitazone treatment is started. Weight gain is the most common adverse effect. Until further data support its safety and efficacy, pioglitazone should not be used to treat patients with NAFLD who do not have biopsy‐proven NASH.
5. True or False: In its guidance statements, the AASLD recommended glucagon‐like peptide‐1 (GLP‐1) receptor agonists as therapeutic agents for patients with NAFLD and NASH.
Answer: B. False. The AASLD stated that it is premature to consider GLP‐1 agonists to specifically treat liver disease in patients with NAFLD or NASH.
6. The AASLD recommends treatment with vitamin E for which of the above patient populations?
Answer: C. Biopsy‐proven NASH without T2D. Vitamin E administered at 800 IU/d improves liver histology in adults with biopsy‐proven NASH who do not have T2D and may be considered for these patients. Vitamin E is not recommended for NASH in patients with T2D, NAFLD without liver biopsy, NASH cirrhosis, or cryptogenic cirrhosis.
7. According to AASLD guidance statements, treatment with foregut bariatric surgery may be considered on a case‐by‐case basis by an experienced bariatric surgery program for which patients?
Answer: D. Otherwise eligible patients with compensated NASH or cryptogenic cirrhosis. The AASLD guidance indicates that foregut bariatric surgery may be considered in otherwise eligible obese patients with NAFLD or NASH; considering the surgery as an established option to specifically treat NASH is premature; and the type, safety, and efficacy of the surgery in otherwise eligible obese patients with established cirrhosis attributed to NAFLD are not established.
8. True or False. Patients who have NAFLD or NASH are at higher risk for serious liver injury from taking statins.
Answer: B. False. Patients with NAFLD or NASH are not at higher risk for liver injury with statin treatment, and the agents can be used to treat dyslipidemia. Statins may be used in patients with NASH cirrhosis but should be avoided in patients with decompensated cirrhosis. Aggressive modification of CVD risk factors should be considered in all patients with NAFLD because this population is at high risk for CV morbidity and mortality.