FAST Scores Inadequate for NASH-F Risk Stratification

Pankaj Aggarwal, MD

Data presented at the American College of Gastroenterology (ACG) 2020 conference showed that the FAST score is insufficient for risk-stratification in patients with fatty liver.

Results from a new study demonstrated that only 1/3 of patients with liver stiffness measurement indicating high risk for advanced fibrosis had concordant FAST scores. However, about 18% would have been considered low risk according to FAST despite having a high liver stiffness measurement.

The FAST score has been used to help identify and stratify patients at risk for non-alcoholic steatohepatitis with advanced fibrosis (NASH-F).

A team, led by Pankaj Aggarwal, MD, of the University of Texas Health Science Center, San Antonio, assessed the utility of the FAST score for patients with suspected fatty liver in identifying those who may require NASH pharmacotherapy.

To do this, they evaluated the concordance between liver stiffness measurement by vibration controlled transient elastography (VCTE) and the FAST score.

The presence of NASH-F was ruled in with a FAST score ≥0.67. Conversely, NASH-F was ruled out with a FAST score ≤0.35.

In their analysis, they only included patients with a liver stiffness measurement ≥10 kPa. Thus, they assessed a total of 665 patients with suspected fatty liver, of which 67.6% were female and 66.9% were Hispanic.

Of the population, 29.8% had diabetes, 58.2% had hypertension, 75.9% had dyslipidemia, and 46.8% had metabolic syndrome.

Furthermore, a total of 20.8% (n = 138) had a liver stiffness measurement ≥10 kPa, an indicator of advanced fibrosis.

Within this cohort, only 36.2% had FAST ≥ 0.67, which indicated concordance with liver stiffness measurement.

On the other hand, 18.1% reported FAST scores ≤0.35—a discordance between measurements.

“Interestingly, 24/25 (96%) of patients in this group had AST < 30 U/L,” the investigators wrote.

They also noted that another 45.6% of patients with a liver stiffness measurement ≥10 kPa had indeterminate FAST scores between 0.35-0.67.

When comparing the FAST ≥ 0.67 cohort with the ≤0.35 cohort, the former was found to have lower platelets (231.1 vs 279.9, respectively, P = .01), higher alanine aminotransferase (104.0 vs 25.2, P < .01), and higher ferritin (279.4 vs 100.9, P = .01).

Aggarwal and colleagues did not report any significant difference in gender as well as likelihood to have diabetes, hypertension, dyslipidemia, or metabolic syndrome.

“The FAST score should not be used alone to risk-stratify patients with fatty liver especially in those with AST < 30 U/L, and providers should be familiar with liver stiffness measurement cutoffs and interpretation,” they concluded.

NASH and non-alcoholic fatty liver disease (NAFLD) are conditions that are notoriously difficult to treat, and new and more personalized treatments are warranted. Furthermore, research has shown opioid use to be especially high in this patient population, especially in those with cirrhosis, higher body mass indexes (BMI), and comorbid psychiatric disorders.

The study, “Evaluation of the FAST Score in Patients With Nonalcoholic Fatty Liver Disease and High Liver Stiffness Measurements,” was published online by ACG.