Address Weight Issues in Patients with Nonalcoholic Liver Disease

From the American Association of Clinical Endocrinologists

CHICAGO?As the number of patients who develop obesity-related conditions continues to mount, physicians will be seeing more patients with nonalcoholic fatty liver disease (NAFLD). At the annual meeting of the American Association of Clinical Endocrinologists, Arun Sanyal, MD, a hepatologist at Virginia Common?wealth University, presented strategies for diagnosing and treating this group of liver disorders that includes both nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH).

Epidemiologic data support a strong relationship between insulin resistance and the pathogenesis of NAFLD. Although not all patients with NAFLD have the metabolic syndrome, most have insulin resistance. Thus, strategies that also address obesity and the metabolic syndrome can most effectively treat NAFLD, according to Dr Sanyal.

While the majority of patients with NAFLD present with abnormal liver function tests (LFTs) or abnormal liver imaging studies, some patients have with both.

Physicians treating patients with abnormal LFTs should first exclude viral hepatitis, since patients with abnormal LFTs, additional features of the metabolic syndrome, and no evidence of viral hepatitis are likely to have NAFLD. Dr Sanyal rarely orders a computed tomography or magnetic resonance imaging scan of the liver, because these expensive tests cannot distinguish between steatosis and steatohepatitis. They also do not provide information on fibrosis and overall prognosis. "A liver biopsy is the only way to assess the prognosis of an individual," he said.

Treatment of NAFLD in patients with the metabolic syndrome includes management of hypertension, diabetes, dyslipidemia, and obesity. Standard obesity management that promotes diet and exercise can help patients lose weight. Weight-loss drugs, however, have shown mixed results, according to Dr Sanyal.

Results from a nonrandomized study have shown improvement in LFTs and ultrasound studies in patients with NASH but also increases in alkaline phosphatase. Thus, weight-loss drugs should not be considered standard ?treatment until more research is ?available, he noted.

Drug treatment for NAFLD may be beneficial. "Currently, insulin sensitizers are the most promising treatment," said Dr Sanyal. Pioglitazone (Actos) improves liver histology more effectively than metformin (Glucophage), but small trial sizes have limited the impact of these data. A larger trial of about 250 patients is expected to shed more light on the benefit of the drug for NASH treatment.

In addition to drug therapy, "for people with a body mass index greater than 35, weight-loss surgery appears to provide substantial benefit," said Dr Sanyal.

Children can also develop obesity-related liver disease, a diagnosis that Dr Sanyal believes is often missed. "There are a lot of kids with NASH," he said.