Treatment and Management

Overview

While many drugs are in development, current treatment across the NAFLD spectrum focuses on maximizing treatment of metabolic syndrome/diabetes, lifestyle modifications and weight loss. Motivating patients towards healthy eating and exercise plays a large role in the management of NAFLD. See the Patient Education module for several resources to help you in this endevour. Benefits occur with even small milestones:

  • 10% weight loss results in reversal of fibrosis stage in NASH
  • Only 5% weight loss is needed to stabilize fibrosis in NASH

Although not FDA approved for NAFLD, current pharmacological interventions supported by guidelines include

  • Vitamin E
  • pioglitazone

However, guidelines only recommend their use when biopsy has proven NASH. Therefore, treatment with these medications should be deferred to specialist.

Weight loss surgery and pharmacotherapeutics targeting weight loss play a useful role in patients with NAFLD. Pharmacotherapeutics are appropriate when BMI is ≥ 30 kg/m2 or when BMI of ≥ 27 kg/m2 and at least one associated comorbid medical condition such as hypertension, dyslipidemia, type 2 diabetes (T2DM), and obstructive sleep apnea are present (Apovian et al., 2015) . See Bibliography & Guidelines module for a link to these guidelines.

When to Refer to a Specialist

  • Suspicion for advanced fibrosis (NAFLD fibrosis score > -1.455)
  • alcoholic liver disease or viral hepatitis cannot be excluded as the cause of laboratory or radiographic abnormalities
  • evidence of cirrhosis – often first identified by imaging or when evaluated for new GI bleed.
    • decompensated cirrhosis occurs when ascites, hepatic encephalopathy and/or esophageal varices are present.
    • compensated cirrhosis can often be “silent”

Collaborating with Specialists

  • Statin use is not contraindicated in patients with NASH, advanced fibrosis, or cirrhosis and is, in fact, recommended due to higher cardiovascular comorbidities in these patients. Additionally, statins are often underprescribed in patients with NAFLD. Atorvastatin is the only statin to show cardiovascular benefit, specifically in patients with NAFLD (Chatrath, Vuppalanchi, & Chalasani , 2012). If decompensated cirrhosis develops, then discontinuing statins is recommended.
  • alcohol is allowable if neither compensated or decompensated cirrhosis is present and as long as it is less than 1 standard drink per day

When Cirrhosis is Present

  • Serum AFP every 6 months (monitor for hepatocellular carcinoma)
  • EGD every 6 months (monitor for esophageal varices)
  • Hepatic ultrasound every 6 months to monitor for hepatocellular carcinoma
  • A low sodium diet may be needed if ascites or peripheral edema is present.

Motivational Interviewing

Motivational interviewing (MI) is a way to converse with patients that helps a patient realize his or her commitment to a goal and explore their motivations and barriers to change. Motivational interviewing focuses on change talk rather than advice giving. It helps the patient develop a trusting relationship with a health care practitioner and creates an environment that supports change. A mainstay of practice for problems like substance abuse, MI is useful in helping patients achieve weight loss and other lifestyle changes and has been specifically proposed for NAFLD. It can be effective in as little as one session.

  • STOP Obesity Alliance – For more information on how to bill for motivational interviewing (p. 4) and how to talk to patients about their weight.
  • MI: Example conversations – Example conversations using motivational interviewing to influence change
  • MI – 1 hour course – Want to use motivational interviewing even more? You can complete this online CEU on motivational interviewing for only $20

Case Study on Management of NAFLD

Bill is a 50 year old male whom has NASH who comes in for his diabetic check up with you. He saw the hepatologist last month and had a repeat liver biopsy. His fibrosis score on biopsy showed a stage 3 fibrosis. 4 years ago it was stage 2. Bill has T2DM and is on metformin and Lantus. His HgB A1C is 7.1. His BMI is 39 kg/m2. H Currently, all labs including glomelurlar filtration rate and liver transamines are all within normal limits . Bill is concerned about the progression of his NASH. He asks if it is too late to “fix this”. He does not drink alcohol. He is interested in lifestyle changes but doesn’t know “where to start”. He knows the hepatologist told him he needs to lose weight, but he is having trouble deciding how he can do this. The hepatologist also gave him a prescription for Victoza but Bill is not sure why. Medications: vitamin E 400mg daily ; Lantus 30mg qhs; lisinopril 10mg daily; atorvastatin 20mg daily; Victoza 1.8 mcg subq daily.

How would you approach this patient? Can he still be on atorvastatin given that he has a chronic liver disease?

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