Review of the 2022 ACCE Guidelines for Non-Alcoholic Fatty Liver Disease

Background

This guideline aims to educate primary care providers, endocrinologists, and other healthcare professionals about non-alcoholic fatty liver disease (NAFLD). Early detection and treatment of this disease is essential.

Research has shown that economic, genetic, social and environmental factors play a role. Current research lacks ethnic and racial demographics, which can make it difficult to treat patients. If left untreated, NAFLD can lead to serious complications.

The most common cause of death in patients with NAFLD is cardiovascular disease. NAFLD also increases the risk of hepatocellular carcinoma and may surpass hepatitis B and C as the leading cause of this cancer.

The most common cause of chronic liver disease is NAFLD, which affects 25% of the world’s population. This is a public health crisis and treatment strategies are constantly evolving.

Risk factors for NAFLD and advanced fibrosis include:

  • Type 2 diabetes
  • Fatty liver
  • Elevated liver enzymes for > 6 months
  • Metabolic syndrome
  • Obesity
  • male sex

Screening

The GOLD standard for diagnosing NAFLD is a liver biopsy, but it is not commonly used due to its cost and invasive nature. FIB-4 (non-invasive liver fibrosis assessment) can be performed to diagnose this disease based on age, AST, ALT, and platelet count.

An FIB-4 test has classifications of high risk (>2.67), indeterminate (1.3-2.67), and low risk (

Patients classified with a high-risk score should undergo further evaluation and testing by a hepatologist. Screening for NAFLD in children, adolescents, and adults with type 2 diabetes includes testing for elevated liver enzymes and coexisting etiologies for chronic liver disease. After a FIB-4 is completed, a FibroScan or Enhanced Liver Fibrosis (ELF) test can be used to test for advanced fibrosis.

Four criteria must be explored before confirming a diagnosis of NAFLD:

  1. Hyperspectral imaging or histology of a tissue sample.
  2. No significant history of alcohol consumption or abuse.
  3. No history of hidradenitis suppurativa.
  4. No existing chronic liver disease.

Healthcare providers should also consider other common causes of NAFLD, including hepatitis C, current medications, alcohol use, Wilson’s disease, severe malnutrition, and parenteral nutrition.

Management

After a patient is diagnosed with NAFLD, lifestyle modifications with diet and exercise are the first-line treatment. The Mediterranean diet has been shown to help with fatty liver disease and insulin sensitivity.

Patients should avoid drinking alcohol and there is limited evidence that drinking black coffee may reduce liver fibrosis. A weight loss of 3 to 10% can slow the progression of the disease.

Bariatric surgery may be an option in patients with a BMI ≥ 35 kg/m^2. Lifestyle modifications are the cornerstone of treatment. There are no FDA-approved drugs for the treatment of NAFLD, however, some drugs have shown benefit.

Medications are no longer recommended due to lack of efficacy:

  • Metformin: Reduces insulin resistance and aminotransferase levels, but no significant improvement in liver histology.
  • Omega-3 fatty acids: only shown to improve cholesterol and reduce inflammation, but does not decrease steatohepatitis or liver fibrosis.
  • DPP-4 inhibitors, insulin and acarbose: No benefit found for hepatocyte inflammation or necrosis.
    • In patients with type 2 diabetes, may be continued to treat hyperglycemia

2022 Guideline Updates

  • Recommend a GLP-1 or pioglitazone for medication management for patients with type 2 diabetes and NASH.
  • Recommend weight management medications such as semaglutide 2.4 mg weekly or liraglutide 3 mg daily for BMI ≥ 27 kg/m^2.
  • Consider an SGLT-2 for patients with type 2 diabetes and NAFLD.
  • Experts are considering changing the name of NAFLD to metabolism-associated fatty liver to describe the etiology of the disease more appropriately.

about the authors

Author: Dawn Royer, 2023 PharmD Candidate, University of Minnesota – Duluth

Tutor: Chelsea Morken, PharmD, PGY-2 Ambulatory Care Resident, Mayo Clinic Health System – Mankato

References

Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, et al. The diagnosis and management of nonalcoholic fatty liver disease: practice guidelines from the American Association for the Study of Liver Diseases, the American College of Gastroenterology, and the American Gastroenterological Association.HEPATOLOGY 2012; 55:2005-2023.

Cusi K, Isaacs S, Barb D, et al. American Association of Clinical Endocrinology Clinical Practice Guidelines for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings: Co-sponsored by the American Association for the Study of liver disease (AASLD). Practice Endocr. 2022;28(5):528-562. do I: 10.1016/j.eprac.2022.03.010

Dumas, Michael, et al. “The role of statins in the management of non-alcoholic fatty liver disease.” Current Pharmaceutical Design vol. 24.38 (2018): 4587-4592. doi:10.2174/1381612825666190117114305

Gawrieh, Samer, et al. “Relation of ELF and PIIINP with liver histology and response to vitamin E or pioglitazone in the PIVENS trial.” Hepatology Communications vol. 5.5 786-797. February 5, 2021, doi:10.1002/hep4.1680

Satapathy, Sanjaya K et al. “Drug-induced fatty liver disease: an overview of pathogenesis and management.” » Annals of Hepatology vol. 14.6 (2015): 789-806.doi:10.5604/16652681.1171749

Younossi, Zobair M et al. “AGA Clinical Practice Update on Lifestyle Modification Using Diet and Exercise to Achieve Weight Loss in the Management of Non-Alcoholic Fatty Liver Disease: A Review of experts.” Gastroenterology flight. 160.3 (2021): 912-918. doi:10.1053/j.gastro.2020.11.051

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