New clinical practice guidelines for the diagnosis and management of nonalcoholic fatty liver disease (NAFLD) are the first to be specifically targeted in primary care and endocrinology clinical settings.
They include 34 evidence-based clinical practice recommendations for examination, diagnosis, management and referral, presented in a table and algorithm flow chart as well as detailed text.
The new guidelines were provided by the American Association of Clinical Endocrinology (AACE) and co-sponsored by the American Association for the Study of Liver Diseases. It was presented on May 12 at the AACE 2022 Annual Meeting and simultaneously published in Endocrine exercise.
This is the ‘first of this kind in this field of medicine. The vast majority of patients with nonalcoholic fatty liver are seen in primary care and endocrinology settings. Only when they reach the most advanced disease are they referred to liver specialists. Therefore, we need to be We are the ones diagnosing and managing these patients because there aren’t enough liver specialists to do that, said Scott Isaacs, MD, of the guide-writing committee, Medscape Medical News.
80 million Americans have NAFLD, but few are aware of it
The range of nonalcoholic steatohepatitis ranges from non-progressive steatosis to the progressive states of nonalcoholic steatohepatitis (NASH), nonalcoholic steatohepatitis (NASH) and end-stage nonalcoholic steatohepatitis (NASH). And NASH, in turn, is a major cause of liver cancer. NAFLD is also closely associated with insulin resistance, type 2 diabetes, atherosclerosis, and myocardial dysfunction.
The global prevalence of nonalcoholic fatty liver disease is about 25% and NASH is about 12% to 14%. However, a recent study found that, among patients in endocrinology and primary care clinics, more than 70% of patients with type 2 diabetes and more than 90% with type 2 diabetes who had a body mass index (BMI) above 35 kg / M2 They also had NAFLD, and more than 20% of these patients had significant cirrhosis.
Of the problems, very few people realize that they have either. “It’s very common. At least 80 million Americans have this but only about 6% know they have it. We talk about it a lot, but it’s not talked about enough,” said Isaacs, an endocrinologist in Atlanta, Georgia.
In fact, most cases of NAFLD are diagnosed by chance when people undergo an ultrasound or CT scan for another reason. Isaacs noted that in about 70% of cases, liver enzymes are normal, and these patients rarely undergo liver tests.
Suthat Liangpunsakul, MD, wrote in an accompanying editorial: “From my perspective, as a hepatologist, this AACE guide is very practical and easy to integrate into routine practice in primary care and endocrinology settings…early identification and risk classification for patients with NAFLD, especially the degree of cirrhosis, required to reduce primary care costs and triage unexplained specialist care referrals.”
Liangpunsakul, UCSD professor of medicine, added that, “An effective screening strategy may also identify those in primary care and endocrinology settings who may benefit from appropriate hepatologists referral before developing complications of portal hypertension, decompensated liver disease, and hepatocellular carcinoma.” “. Department of Gastroenterology and Hepatology at Indiana University School of Medicine, Indianapolis.
Screening with the new FIB-4 test is recommended
The guidelines call for screening of all patients at risk for nonalcoholic fatty liver, including those with prediabetes, type 2 diabetes, obesity, and/or two or more cardiac metabolic risk factors, or those with hepatic steatosis. Existing on imaging, and/or with persistently elevated plasma aminotransferase levels (ie for more than 6 months).
The recommended screening test is the FIB-4 index (FIB-4), calculated using the patient’s age, AST level, platelet count (PLT), and ALT level: FIB-4 score = Age (in years) x AST (U/L)/[PLT (109/L) x ALT ½ (U/L).
Recently approved by the US Food and Drug Administration (FDA), the FIB-4 has been demonstrated to help identify liver disease in primary care settings.
“We really want to encourage clinicians to do the screening. The first step is the FIB-4 test. It’s a mathematical calculation using blood tests that we do anyway,” Isaacs told Medscape Medical News.
The FIB-4 stratifies patients as being low, intermediate, or high risk for liver fibrosis. Those at low risk can be managed in primary care or endocrinology settings with a focus on obesity management and cardiovascular disease prevention. “Those at low risk on FIB-4 still have a high cardiovascular disease risk. They still need to be managed,” Isaacs observed.
For those at intermediate risk, a second noninvasive test — either a liver stiffness measurement by elastography or an enhanced liver fibrosis (ELF) test — is advised. If the patient is found to be at high risk or is still indeterminant after two non-invasive tests, referral to a liver specialist for further testing, including possible biopsy, is advised.
Those found to be at high risk with the FIB-4 should also be referred to hepatology. In both the intermediate- and high-risk groups, management should be multidisciplinary, including a hepatologist, endocrinologist, and other professionals to prevent both cardiovascular disease and progression to cirrhosis, the guidelines say.
“The diagnosis isn’t about diagnosing liver fat. It’s about diagnosing fibrosis, or the risk for clinically significant fibrosis. That’s really where the challenge lies,” Isaacs commented.
NAFLD Treatment in Endocrinology and Primary Care: CVD Prevention
During the presentation at the AACE meeting, guideline panel co-chair Kenneth Cusi, MD, chief of endocrinology, diabetes, and metabolism at the University of Florida, Gainesville, summarized current and future treatments for NAFLD.
Lifestyle intervention, cardiovascular risk reduction, and weight loss for those who are overweight or obese are recommended for all patients with NAFLD, including structured weight loss programs, anti-obesity medications, and bariatric surgery if indicated.
There are currently no FDA-approved medications specifically for NASH, but pioglitazone, approved for type 2 diabetes, and glucagon-like peptide-1 (GLP-1) agonists, approved for type 2 diabetes and weight loss, have been shown to be effective in treating the condition and preventing progression. Other treatments are in development, Cusi said.
The guideline also includes a section on diagnosis and management of NAFLD in children and adolescents. Here, the FIB-4 is not recommended because it isn’t accurate due to the age part of the equation, so liver enzyme tests are used in pediatric patients considered at high risk due to clinical factors. Management is similar to adults, except not all medications used in adults are approved for use in children.
In the editorial, Liangpunsakul cautions that “the level of uptake and usage of the guideline may be an obstacle.”
To remedy that, he advises that “the next effort should gear toward distributing this guideline to the targeted providers and developing the ‘feedback platforms’ on its execution in the real-world…The successful implementation of this AACE guideline by the primary care providers and endocrinologists, hopefully, will deescalate the future burden of NAFLD-related morbidity and mortality.”
Isaacs and Liangpunsakul have reported no relevant financial relationships. Cusi has reported receiving research support towards the University of Florida as principal investigator from the National Institute of Health, Echosens, Inventiva, Nordic Bioscience, Novo Nordisk, Poxel, Labcorp, and Zydus, and is a consultant for Altimmune, Akero, Arrowhead, AstraZeneca, 89Bio, BMS, Coherus, Intercept, Lilly, Madrigal, Merck, Novo Nordisk, Quest, Sagimet, Sonic Incytes, Terns, and Thera Technologies.
AACE 2022 Annual Meeting. Presented May 12, 2022.
Endocr Pract. Published online May 15, 2022. Full text, Editorial
Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR’s Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.
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