Management of NASH

Management of nonalcoholic steatohepatitis with current guidelines. Any treatment for NASH should aim at improving NASH-related mortality and reducing progression to cirrhosis or HCC

Management of NASH nonalcoholic steatohepatitis

Any treatment for NASH should aim at improving NASH-related mortality and reducing progression to cirrhosis or HCC. Currently, there are no Food and Drug Administration (FDA)-approved or European Medicines Agency (EMA)-approved therapies for NASH and only lifestyles interventions are recommended for the treatment of NASH.

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Lifestyle interventions

The close relationship between unhealthy lifestyle and NAFLD makes lifestyle correction mandatory in all patients, with the potential not only to improve liver disease, but also hyperglycaemia, atherogenic dyslipidaemia and high blood pressure. Relatively small amounts of weight loss reduce liver fat and improve hepatic insulin resistance.

Bariatric surgery

Bariatric surgery is an efficient method to achieve significant weight loss, reverse insulin resistance, and reduce cardiovascular risk and long-term mortality. A meta-analysis on the effect of bariatric surgery in NAFLD revealed that the pooled proportion of patients with improvement or resolution was 91.6% for steatosis, 81.3% for steatohepatitis, 65.5% for fibrosis, and that 69.5% of patients experienced complete resolution of NASH. Nevertheless, the AASLD practice guidance states that while bariatric surgery can be considered in otherwise eligible patients with NAFLD or NASH, it is premature to consider it as an established option for the treatment of NASH.


Suggested Intervention

Energy restriction

  • 500 – 1000kcal energy defect
  • 7 – 10% total weight loss target
  • long-term maintenance approach

Alcohol intake

  • strictly keep alcohol below the risk threshold
    (30g, men, 20g, women)
Exercise/ physical activity
  • Moderate-intensity aerobic physical activities
    (150 – 200 min/week)
  • 3-5 sessions
  • Resistance training


European and U.S. guidelines recommend that pharmacotherapy should be reserved for patients with biopsy-proven NASH, particularly those with significant fibrosis (stage F2 and higher), but also those with early-stage NASH who are at high risk of disease progression. As yet, no drugs have been approved for treatment of NASH and thus any recommendation for pharmacological therapy is off label. However, the EASL-EASD-EASO guideline states that pioglitazone or vitamin E or their combination may be used for NASH.

RELATED Nash management ARTICLES

  1. Bower G, Toma T, Harling L, et al. Bariatric surgery and non-alcoholic fatty liver disease: a systematic review of liver biochemistry and histology. Obes Surg. 2015;25(12):2280-9.
  2. Budd J, Cusi K. Role of agents for the treatment of diabetes in the management of nonalcoholic fatty liver disease. Curr Diab Rep. 2020 Oct 5;20(11):59.
  3. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. 2018;67(1):328-57.
  4. Dufour JF, Caussy C, Loomba R. Combination therapy for non-alcoholic steatohepatitis: rationale, opportunities and challenges. Gut. 2020 Oct;69(10):1877-1884
  5. European Association for the Study of the Liver (EASL); European Association for the Study of Diabetes (EASD); European Association for the Study of Obesity (EASO). EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016 Jun;64(6):1388-402.
  6. Mummadi RR, Kasturi KS, Chennareddygari S, Sood GK. Effect of bariatric surgery on nonalcoholic fatty liver disease: systematic review and meta-analysis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2008;6(12):1396-402
  7. Muthiah MD, Sanyal AJ. Current management of non-alcoholic steatohepatitis. Liver Int. 2020; 40(Suppl 1):89-95
  8. Younossi ZM, Corey KE, Lim JK. AGA clinical practice update on lifestyle modification using diet and exercise to achieve weight loss in the management of nonalcoholic fatty liver disease: expert review. Gastroenterology. 2021 Feb;160(3):912-918