New practice guidance released for NAFLD

The American Association for the Study of Liver Diseases has released new clinical practice guidance on assessing and managing patients with nonalcoholic fatty liver disease (NAFLD).

The guidance addressed several comorbid conditions commonly associated with NAFLD, including cardiovascular disease (CVD) and diabetes. It recommended using statins for CVD risk reduction in patients with all levels of NAFLD, including compensated cirrhosis, but noted that there are limited safety and efficacy data on statins in patients with decompensated cirrhosis. Lifestyle changes and supplementation with omega-3 fatty acids, icosapent ethyl, or fibrates can help manage hypertriglyceridemia. Regarding diabetes, the guidance said that clinicians should screen patients with NAFLD for type 2 diabetes and should screen those with diabetes for advanced fibrosis due to the increased risk for nonalcoholic steatohepatitis (NASH).

The guidance stated that alcohol can be a cofactor for liver disease progression in patients with NAFLD and that clinicians should assess alcohol intake on a regular basis. Patients with clinically significant hepatic fibrosis should abstain from alcohol use completely, the guidance said.

While the guidance did not recommend general population-based screening for NAFLD, all patients with hepatic steatosis or clinically suspected NAFLD based on the presence of obesity and metabolic risk factors should undergo primary risk assessment with the fibrosis-4 (FIB-4) score. Clinicians should screen for advanced fibrosis in patients at high risk, such as those with type 2 diabetes, medically complicated obesity, a family history of cirrhosis, or more than mild alcohol consumption. Patients with prediabetes, type 2 diabetes, or at least two metabolic risk factors or evidence of hepatic steatosis on imaging should have primary risk assessment with FIB-4 repeated every one to two years, according to the guidance.

Clinicians should prescribe a diet that leads to a caloric deficit and encourage increased activity levels in patients with NAFLD who are overweight or obese, the guidance said. When possible, encourage diets with limited carbohydrates and saturated fat that are enriched with high fiber and unsaturated fats (e.g., the Mediterranean diet) due to their additional cardiovascular benefits, according to the guidance. The guidance also noted that clinicians should consider bariatric surgery in patients who meet the criteria.

While there are currently no FDA-approved medications to treat NAFLD, clinicians may consider drugs approved for associated comorbidities when appropriate, the guidance said. They can consider semaglutide and pioglitazone for their approved indications in patients with NASH, as well as vitamin E, which studies have shown improves NASH in patients without diabetes. However, metformin, ursodeoxycholic acid, dipeptidyl peptidase-4 inhibitors, statins, and silymarin do not offer meaningful histologic benefit in NASH and do not have a role in treating this condition, according to the guidance.

The guidance statement also includes recommendations on screening in patients with a family history of NASH, biomarkers and noninvasive tests for the diagnosis and assessment of NAFLD, surrogate markers of histological treatment response, and associated endocrine disorders. It was published March 17 by Hepatology.