NAFLD Diagnosis and Management Guidelines Issued

Laurie Barclay, MD

June 27, 2012

June 27, 2012 — Suitable interventions in some patients with nonalcoholic fatty liver disease (NAFLD) may include weight loss, vitamin E, and/or pioglitazone, according to a new practice guideline. The American Association for the Study of Liver Diseases (AASLD), American College of Gastroenterology (ACG), and American Gastroenterological Association issued the new recommendations for NAFLD diagnosis and management, which are published in the June issue of Hepatology.

"The definition of [NAFLD] requires that (a) there is evidence of hepatic steatosis, either by imaging or by histology and (b) there are no causes for secondary hepatic fat accumulation such as significant alcohol consumption, use of steatogenic medication or hereditary disorders," write Naga Chalasani, MD, FACG, from the Indiana University School of Medicine in Indianapolis, and colleagues. "In the majority of patients, NAFLD is associated with metabolic risk factors such as obesity, diabetes mellitus, and dyslipidemia. NAFLD is histologically further categorized into nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH)."

Highlights of the recommendations in adults include the following:

  • Weight loss generally reduces hepatic steatosis, but up to 10% weight loss may be needed to improve necroinflammation.

  • Patients with NAFLD should not consume heavy amounts of alcohol.

  • Vitamin E (a-tocopherol), 800 IU/day, improves liver histology in nondiabetic adults with biopsy-proven NASH. It should therefore be considered as a first-line pharmacotherapy for this patient population, but not in other patients, pending further evidence supporting its efficacy.

  • Omega-3 fatty acids may be considered as first-line therapy for hypertriglyceridemia in patients with NAFLD, but it is premature to recommend them for the specific treatment of NAFLD or NASH.

  • Metformin is not recommended as a specific treatment for liver disease in adults with NASH.

  • Pioglitazone may be used to treat steatohepatitis in patients with biopsy-proven NASH, but long-term safety and efficacy have not been established.

  • Foregut bariatric surgery is not contraindicated in otherwise eligible obese individuals with NAFLD or NASH but without established cirrhosis. However, it is premature to consider foregut bariatric surgery as an established option to specifically treat NASH.

  • Statins can be used to treat dyslipidemia in patients with NAFLD and NASH, but they should not be used to specifically treat NASH, pending evidence from randomized controlled trials.

  • Clinicians should look for metabolic risk factors and alternate etiologies for hepatic steatosis in patients who have other types of chronic liver disease and who also have steatosis and steatohepatitis.

  • Patients with NASH cirrhosis should be screened for gastroesophageal varices and should be considered for hepatocellular carcinoma screening according to the AASLD/ACG practice guidelines.

  • Because of uncertainties surrounding diagnostic tests, treatment options, long-term benefits, and cost-effectiveness, screening for NAFLD is not advised among adults attending primary care clinics or high-risk groups attending diabetes or obesity clinics.

  • Systematic screening of family members of patients with NAFLD is currently not recommended.

  • Competing etiologies for steatosis and coexisting common chronic liver disease must be excluded in patients with suspected NAFLD.

  • Persistently high serum ferritin and increased iron saturation may warrant a liver biopsy, especially in patients with homozygous or heterozygous C282Y HFE (hemochromatosis) gene mutations.

  • Patients with high serum titers of autoantibodies and other features suggesting autoimmune liver disease (eg, very high aminotransferases or high globulin levels) should undergo a more thorough work-up for autoimmune liver disease.

  • Metabolic syndrome predicts the presence of steatohepatitis in patients with NAFLD and can therefore be used to target patients for a liver biopsy.

  • The NAFLD Fibrosis Score helps to identify patients with NAFLD who have a higher likelihood of having bridging fibrosis and/or cirrhosis.

  • Liver biopsy should be considered in patients with suspected NAFLD in whom competing etiologies for hepatic steatosis and coexisting chronic liver diseases cannot be otherwise excluded.

This clinical practice guideline also provides recommendations for the management and treatment of NAFLD in children.

Some of the guideline authors and reviewers report various financial relationships involving Gilead, Genentech, Mochida, Amylin, Eli Lilly, Ikaria, Intercept, Cumberland Pharmaceuticals, J & J, Merck, GlaxoSmithKline, Karo Bio, Salix, Advanced Life Sciences, Bristol Meyers Squibb, Teva Pharmaceuticals, Abbott, Biolex, Sanofi-Aventis, Vertex, Tibotec, Vertex, Norgine, Celgene, Pfizer, Geneva Foundation, Daichi-Sankyo, Roche, Quark Pharmaceuticals, Synageva BioPharma, Raptor Pharmaceuticals, Takeda, Astella, Exhalenz, Immuron, Schering-Plough, and/or Rottapharm.

Hepatology. 2012;55:2005-2023. Full text

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