Jaividhya Dasarathy, MD, FAAFP Sanath Allampati, MD Christine Alexander, MD Arthur McCullough, MD Department of Family Medicine, Metrohealth Medical Center, Cleveland, Ohio (Drs. Dasarathy and Alexander); Department of Hospital Medicine, Cleveland Clinic Foundation, Ohio (Dr. Allampati); Department of Gastroenterology and Hepatology, Cleveland Clinic, Ohio (Dr. McCullough) jdasarathy@metrohealth.org
The authors reported no potential conflict of interest relevant to this article.
Although numerous trials have explored the use of Chinese herbal medicines for non-alcoholic fatty liver disease, the high risk of bias leaves their safety and efficacy open to question.
Pioglitazone is considered a second-line agent. Despite its beneficial effects on insulin sensitivity and hepatic histology, there are concerns about the adverse effects of thiazolidinediones. GLP1 analogues, which improve liver enzymes and reduce hepatic steatosis, are considered third-line agents.
Hypertension. Because approximately 70% of patients with NAFLD have hypertension,35 it is imperative to screen patients for the condition. If blood pressure is >140/90 mm Hg, patients should be managed according to hypertension guidelines. ACE inhibitors or ARBs are recommended as first-line therapy, since blocking the renin-angiotensin system potentially reduces hepatic fibrosis,36 and ARBs may lower transaminases and improve insulin sensitivity in NAFLD.
Dyslipidemia. Treatment of dyslipidemia is essential to lowering cardiovascular mortality in patients with NAFLD. Even though elevated transaminases occur with NAFLD, this should not preclude starting therapy to lower triglycerides to <150 mg/dL and total cholesterol to <200 mg/dL.
OSA. Because of the high prevalence of OSA in patients with NAFLD, physicians should have a high index of suspicion and screen this population for sleep disorders. OSA is associated with an increased risk of NAFLD and advanced fibrosis in NASH.37 Treatment of OSA improves quality of life and controls blood pressure in patients with NAFLD, but it’s currently unclear whether targeting sleep disorders can slow the progression of fibrosis in NAFLD.
Concentrate on the complications of cirrhosis
Patients with NASH cirrhosis, like those with cirrhosis of other etiologies, are at risk for complications, including hepatic encephalopathy, ascites, hepatorenal syndrome, and esophageal variceal hemorrhage. Surveillance to detect these include an annual liver ultrasound, an alpha-fetoprotein test every 6 months, esophagogastroduodenoscopy for varices, and an assessment for liver transplantation. For more on these complications, see, “Cirrhosis complications: Keeping them under control,” J Fam Pract. 2015;64:338-342. NAFLD-associated cirrhosis is the third most frequent indication for liver transplantation in the United States and may become the most frequent indication in the next decade.38
CASE › Because the patient’s liver biopsy showed early NASH, we recommended that he aggressively pursue lifestyle modification, including regular physical activity and dietary changes. Additionally, we discussed optimization of glycemic control and continued use of lisinopril for control of hypertension. On follow-up 6 months later, he had lost weight and his BMI was 32 kg/m2. In addition, his transaminase levels had improved, but they had not normalized.
We recommended that he continue the same measures, with follow-up every 6 months to ensure compliance with lifestyle modifications and with diabetes and hypertension control.
CORRESPONDENCE Jaividhya Dasarathy, MD, Metro Health Medical Center, 2500 Metro Health Drive, Cleveland, OH 44109; jdasarathy@metrohealth.org.
