Josya-Gony Charles, MS, MD

The American College of Gastroenterology and the American Gastroenterological Association together released new guidelines in the spring of 2012 for the diagnosis and management of nonalcoholic fatty liver disease.

NAFLD is defined as histological or imaging evidence of hepatic steatosis without evidence of a secondary cause of fat accumulation, such as large amounts of alcohol consumption. It is further categorized as nonalcoholic fatty liver (NAFL), which is the presence of hepatic steatosis with no hepatocellular injury; and nonalcoholic steatohepatitis (NASH), which is the presence of hepatic steatosis and inflammation with hepatocyte injury with or without fibrosis.

The prevalence of NAFLD varies among studies, but they suggest a prevalence in the general population of approximately 20%, with a prevalence of NASH of approximately 3%-5%.

Obesity is an important risk factor for NAFLD, with studies showing that up to 90% of patients undergoing bariatric surgery have NAFLD, and 70% of patients with type 2 diabetes have NAFLD. Other risk factors include increasing age, male gender, hypothyroidism, polycystic ovary syndrome, and sleep apnea.

In general, patients with NAFL with steatosis and no inflammation have slow progression of their liver disease, and their main health risks are associated with the metabolic syndrome and obesity that led to the NAFLD. Patients with NASH can have a more severe course, with histological progression to cirrhosis.

Screening

NAFLD screening is not recommended for either average-risk or high-risk patients, due to insufficient evidence of benefit. Screening family members of patients with NAFLD also is not recommended. When patients have abnormal liver enzymes or are symptomatic, evaluation should be conducted for suspected NAFLD.

Evaluation

Patients should be evaluated for other causes of hepatic steatosis, including excessive alcohol use, hepatitis C, medications, and other causes of liver disease. It is not unusual for patients with NAFLD to have elevated ferritin; if that is found, then genetic testing for hemochromatosis should be performed. If genetic testing is positive for the hemochromatosis gene, then a biopsy should be considered.

Liver biopsy is the only reliable method to fully define steatohepatitis and fibrosis, but its use should be reserved for those patients most likely to benefit from the information obtained. Biopsy should be considered in patients with NAFLD who are at increased risk of having steatohepatitis and advanced fibrosis, including those with the metabolic syndrome, elevated NAFLD fibrosis scores, and elevated liver function tests.

Liver biopsy is not recommended in patients who are asymptomatic, have normal liver enzymes, but who have incidental hepatic steatosis discovered during imaging. In addition, liver biopsy should be considered when competing etiologies are being considered in cases of hepatic steatosis and coexisting chronic liver disease.

Management

Weight loss helps reduce hepatic steatosis. A loss of 3%-5% body weight is needed, but a greater loss (up to 10%) can help improve necroinflammation. This can be achieved via caloric restriction or increased physical activity. Bariatric surgery does not have enough evidence to support its use in the treatment of NASH. However, it is not contraindicated in obese patients who have NAFLD or NASH.

Vitamin E (800 IU/day) can help patients with NASH, and should be first-line therapy in nondiabetic patients. There is not enough data to support its use in diabetics. Consideration of use of vitamin E must be weighed against evidence from published studies showing possible increases in mortality with high-dose vitamin E and an increase in prostate cancer in men.

Metformin is not recommended as a treatment for liver disease in patients with NASH, as it has no significant effect on liver histology. Ursodeoxycholic acid is not recommended for treatment. There is limited evidence to support using omega-3 fatty acids to treat NAFLD, but they can be used as a first-line therapy for hypertriglyceridemia in NAFLD patients. Pioglitazone may help, but long-term safety and efficacy in patients with NASH are not well studied.

Statins can be used to treat dyslipidemia in patients with NAFLD and NASH, without concern of increased risk for liver toxicity. While there are some early studies that suggest that statins may be beneficial for NAFLD, these studies are far from conclusive and should not be used to justify statins’ use in such cases.

Finally, heavy alcohol use, defined as more than 14 drinks per week in men or 7 drinks per week in women, should be avoided in patients with NAFLD.

The Bottom Line

Routine screening is not recommended for NAFLD. Screen for excessive alcohol consumption. Vitamin E in nondiabetics and weight loss in all patients are first-line treatments. Metformin and ursodeoxycholic acid are not recommended. There is not enough evidence to support the use of pioglitazone. Statins can reduce dyslipidemia in patients with NAFLD and NASH, but they should not be used primarily for NASH therapy. In children, weight loss and lifestyle change are first-line therapies. Perform a liver biopsy in children if the diagnosis is unclear and before starting NASH therapy.

Reference

• Chalasani N., Younossi Z., Lavine J. et al. The Diagnosis and Management of Non-Alcoholic Fatty Liver Disease: Practice Guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology 2012;55:6,2005-23.

Dr. Charles is a resident in the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

The American College of Gastroenterology and the American Gastroenterological Association together released new guidelines in the spring of 2012 for the diagnosis and management of nonalcoholic fatty liver disease.

NAFLD is defined as histological or imaging evidence of hepatic steatosis without evidence of a secondary cause of fat accumulation, such as large amounts of alcohol consumption. It is further categorized as nonalcoholic fatty liver (NAFL), which is the presence of hepatic steatosis with no hepatocellular injury; and nonalcoholic steatohepatitis (NASH), which is the presence of hepatic steatosis and inflammation with hepatocyte injury with or without fibrosis.

The prevalence of NAFLD varies among studies, but they suggest a prevalence in the general population of approximately 20%, with a prevalence of NASH of approximately 3%-5%.

Obesity is an important risk factor for NAFLD, with studies showing that up to 90% of patients undergoing bariatric surgery have NAFLD, and 70% of patients with type 2 diabetes have NAFLD. Other risk factors include increasing age, male gender, hypothyroidism, polycystic ovary syndrome, and sleep apnea.

In general, patients with NAFL with steatosis and no inflammation have slow progression of their liver disease, and their main health risks are associated with the metabolic syndrome and obesity that led to the NAFLD. Patients with NASH can have a more severe course, with histological progression to cirrhosis.

Screening

NAFLD screening is not recommended for either average-risk or high-risk patients, due to insufficient evidence of benefit. Screening family members of patients with NAFLD also is not recommended. When patients have abnormal liver enzymes or are symptomatic, evaluation should be conducted for suspected NAFLD.

Evaluation

Patients should be evaluated for other causes of hepatic steatosis, including excessive alcohol use, hepatitis C, medications, and other causes of liver disease. It is not unusual for patients with NAFLD to have elevated ferritin; if that is found, then genetic testing for hemochromatosis should be performed. If genetic testing is positive for the hemochromatosis gene, then a biopsy should be considered.

Liver biopsy is the only reliable method to fully define steatohepatitis and fibrosis, but its use should be reserved for those patients most likely to benefit from the information obtained. Biopsy should be considered in patients with NAFLD who are at increased risk of having steatohepatitis and advanced fibrosis, including those with the metabolic syndrome, elevated NAFLD fibrosis scores, and elevated liver function tests.

Liver biopsy is not recommended in patients who are asymptomatic, have normal liver enzymes, but who have incidental hepatic steatosis discovered during imaging. In addition, liver biopsy should be considered when competing etiologies are being considered in cases of hepatic steatosis and coexisting chronic liver disease.

Management

Weight loss helps reduce hepatic steatosis. A loss of 3%-5% body weight is needed, but a greater loss (up to 10%) can help improve necroinflammation. This can be achieved via caloric restriction or increased physical activity. Bariatric surgery does not have enough evidence to support its use in the treatment of NASH. However, it is not contraindicated in obese patients who have NAFLD or NASH.

Vitamin E (800 IU/day) can help patients with NASH, and should be first-line therapy in nondiabetic patients. There is not enough data to support its use in diabetics. Consideration of use of vitamin E must be weighed against evidence from published studies showing possible increases in mortality with high-dose vitamin E and an increase in prostate cancer in men.

Metformin is not recommended as a treatment for liver disease in patients with NASH, as it has no significant effect on liver histology. Ursodeoxycholic acid is not recommended for treatment. There is limited evidence to support using omega-3 fatty acids to treat NAFLD, but they can be used as a first-line therapy for hypertriglyceridemia in NAFLD patients. Pioglitazone may help, but long-term safety and efficacy in patients with NASH are not well studied.

Statins can be used to treat dyslipidemia in patients with NAFLD and NASH, without concern of increased risk for liver toxicity. While there are some early studies that suggest that statins may be beneficial for NAFLD, these studies are far from conclusive and should not be used to justify statins’ use in such cases.

Finally, heavy alcohol use, defined as more than 14 drinks per week in men or 7 drinks per week in women, should be avoided in patients with NAFLD.

The Bottom Line

Routine screening is not recommended for NAFLD. Screen for excessive alcohol consumption. Vitamin E in nondiabetics and weight loss in all patients are first-line treatments. Metformin and ursodeoxycholic acid are not recommended. There is not enough evidence to support the use of pioglitazone. Statins can reduce dyslipidemia in patients with NAFLD and NASH, but they should not be used primarily for NASH therapy. In children, weight loss and lifestyle change are first-line therapies. Perform a liver biopsy in children if the diagnosis is unclear and before starting NASH therapy.

Reference

• Chalasani N., Younossi Z., Lavine J. et al. The Diagnosis and Management of Non-Alcoholic Fatty Liver Disease: Practice Guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology 2012;55:6,2005-23.

Dr. Charles is a resident in the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

The American College of Gastroenterology and the American Gastroenterological Association together released new guidelines in the spring of 2012 for the diagnosis and management of nonalcoholic fatty liver disease.

NAFLD is defined as histological or imaging evidence of hepatic steatosis without evidence of a secondary cause of fat accumulation, such as large amounts of alcohol consumption. It is further categorized as nonalcoholic fatty liver (NAFL), which is the presence of hepatic steatosis with no hepatocellular injury; and nonalcoholic steatohepatitis (NASH), which is the presence of hepatic steatosis and inflammation with hepatocyte injury with or without fibrosis.

The prevalence of NAFLD varies among studies, but they suggest a prevalence in the general population of approximately 20%, with a prevalence of NASH of approximately 3%-5%.

Obesity is an important risk factor for NAFLD, with studies showing that up to 90% of patients undergoing bariatric surgery have NAFLD, and 70% of patients with type 2 diabetes have NAFLD. Other risk factors include increasing age, male gender, hypothyroidism, polycystic ovary syndrome, and sleep apnea.

In general, patients with NAFL with steatosis and no inflammation have slow progression of their liver disease, and their main health risks are associated with the metabolic syndrome and obesity that led to the NAFLD. Patients with NASH can have a more severe course, with histological progression to cirrhosis.

Screening

NAFLD screening is not recommended for either average-risk or high-risk patients, due to insufficient evidence of benefit. Screening family members of patients with NAFLD also is not recommended. When patients have abnormal liver enzymes or are symptomatic, evaluation should be conducted for suspected NAFLD.

Evaluation

Patients should be evaluated for other causes of hepatic steatosis, including excessive alcohol use, hepatitis C, medications, and other causes of liver disease. It is not unusual for patients with NAFLD to have elevated ferritin; if that is found, then genetic testing for hemochromatosis should be performed. If genetic testing is positive for the hemochromatosis gene, then a biopsy should be considered.

Liver biopsy is the only reliable method to fully define steatohepatitis and fibrosis, but its use should be reserved for those patients most likely to benefit from the information obtained. Biopsy should be considered in patients with NAFLD who are at increased risk of having steatohepatitis and advanced fibrosis, including those with the metabolic syndrome, elevated NAFLD fibrosis scores, and elevated liver function tests.

Liver biopsy is not recommended in patients who are asymptomatic, have normal liver enzymes, but who have incidental hepatic steatosis discovered during imaging. In addition, liver biopsy should be considered when competing etiologies are being considered in cases of hepatic steatosis and coexisting chronic liver disease.

Management

Weight loss helps reduce hepatic steatosis. A loss of 3%-5% body weight is needed, but a greater loss (up to 10%) can help improve necroinflammation. This can be achieved via caloric restriction or increased physical activity. Bariatric surgery does not have enough evidence to support its use in the treatment of NASH. However, it is not contraindicated in obese patients who have NAFLD or NASH.

Vitamin E (800 IU/day) can help patients with NASH, and should be first-line therapy in nondiabetic patients. There is not enough data to support its use in diabetics. Consideration of use of vitamin E must be weighed against evidence from published studies showing possible increases in mortality with high-dose vitamin E and an increase in prostate cancer in men.

Metformin is not recommended as a treatment for liver disease in patients with NASH, as it has no significant effect on liver histology. Ursodeoxycholic acid is not recommended for treatment. There is limited evidence to support using omega-3 fatty acids to treat NAFLD, but they can be used as a first-line therapy for hypertriglyceridemia in NAFLD patients. Pioglitazone may help, but long-term safety and efficacy in patients with NASH are not well studied.

Statins can be used to treat dyslipidemia in patients with NAFLD and NASH, without concern of increased risk for liver toxicity. While there are some early studies that suggest that statins may be beneficial for NAFLD, these studies are far from conclusive and should not be used to justify statins’ use in such cases.

Finally, heavy alcohol use, defined as more than 14 drinks per week in men or 7 drinks per week in women, should be avoided in patients with NAFLD.

The Bottom Line

Routine screening is not recommended for NAFLD. Screen for excessive alcohol consumption. Vitamin E in nondiabetics and weight loss in all patients are first-line treatments. Metformin and ursodeoxycholic acid are not recommended. There is not enough evidence to support the use of pioglitazone. Statins can reduce dyslipidemia in patients with NAFLD and NASH, but they should not be used primarily for NASH therapy. In children, weight loss and lifestyle change are first-line therapies. Perform a liver biopsy in children if the diagnosis is unclear and before starting NASH therapy.

Reference

• Chalasani N., Younossi Z., Lavine J. et al. The Diagnosis and Management of Non-Alcoholic Fatty Liver Disease: Practice Guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology 2012;55:6,2005-23.

Dr. Charles is a resident in the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.