Treatment Options for Patients With NAFLD, NASH

With no approved medications for the treatment of nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH), health care providers must emphasize lifestyle changes, treatment of comorbidities, and careful staging and monitoring of disease, according to the speaker at the session about Clinical Management of NASH at the American Association for the Study of Liver Diseases (AASLD) annual meeting.

Manal F. Abdelmalek, MD, MPH, who is a professor of medicine at Duke University in Durham, North Carolina, discussed the current treatment options available for patients with NAFLD and NASH.

“Lifestyle modification is a must for all patients with these conditions, no matter what their stage of disease,” she stated. “There are no therapies approved by the US Food and Drug Administration for NAFLD or NASH, so the treatment of comorbidities is the only backbone that we have.”

The first and most important step is weight loss, Dr Abdelmalek said. “The treatment of obesity is the foundation of care for NAFLD and especially for NASH.”

She reported that a systematic review of studies showed that the loss of 4% to 10% of body weight among patients with NAFLD and NASH improves measures of liver fat or serum aminotransaminase and improves hepatic steatosis. “Higher weight loss translates to greater improvements,” she noted.

The review showed improvement in steatosis among 35% to 100% of patients who lost 3% or more of their body weight. From 41% to 100% of patients who shed 5% or more of their body weight saw improvements in ballooning or inflammation. NASH resolution took place in 64% to 90% of patients who lost 7% or more of their body weight; and one-stage fibrosis regression took place in 45% of patients who lost 10% or more of their body weight.

Dietary changes are, of course, needed to effect weight loss, with the avoidance of fructose being “essential,” according to Dr Abdelmalek. Fructose increases appetite, has deleterious effects on the microbiota, induces insulin resistance and is associated with liver injury as well as diabetes. Heavy consumption of red meat and carbohydrates have also been implicated in increasing risk of fatty liver disease. Both coffee and modest use of alcohol can have positive and even protective against liver disease, she said.

Bariatric surgery has been proven effective in helping to resolve NAFLD and NASH, Dr Abdelmalek explained. A study conducted in France showed that 84% of patients who underwent bariatric surgery had resolution of NASH without worsening of fibrosis over 5 years, and in cases of mild fibrosis, some improvement of this condition, as well. 

Effective therapy for NAFLD and NASH also includes working with patients to resolve other lifestyle factors such as smoking and alcohol use, and to treat comorbidities, which often include type 2 diabetes, hypercholesterolemia, hypertension, and other conditions related to obesity and overweight.

Exercise is also important for both weight loss and overall liver health, Dr Abdelmalek said. “Evidence shows that vigorous activity 5 days per week decreased the risk of hepatocellular carcinoma by 44% and also decreases portal pressure. Both aerobic and resistance training have been shown to reduce fat in the liver.”

—Rebecca Mashaw

Reference:

Abdelmalek MF. What are the current treatment options for our patients with NAFLD/NASH? Talk presented at: American Association for the Study of Liver Diseases annual meeting; November 13, 2020. Virtual.