NAFLD: Review of Management for Primary Care Providers

The authors considered NAFLD evaluation, diagnosis, and management in the primary care setting and endocrinology clinics.
PUBLISHED IN: Mayo Clinic Proceedings 2022

Commentary

Nonalcoholic fatty liver disease (NAFLD) refers to the development of hepatic steatosis in the absence of secondary causes. Contrarily to nonalcoholic steatohepatitis (NASH), which refers to inflammation and ballooning with or without fibrosis, NAFLD involves all histopathological changes. Patients with comorbidities associated with NAFLD (type 2 diabetes, obesity, metabolic syndrome, and dyslipidemia) are at high risk of increased cardiovascular morbidity and mortality. Currently, no pharmacologic agents for the treatment of NAFLD or NASH have been approved in the US or in Europe.

The aim of this review by R. Basu, M. Noureddin, and J.M. Clark was to provide insight into NAFLD’s diagnosis and management in primary care centres and endocrinology clinics.

Key learnings:

Individuals with obesity, type 2 diabetes, metabolic syndrome, or dyslipidemia are at a high risk of developing NAFLD. As the epidemics of type 2 diabetes and obesity continue to spread worldwide, the number of patients with NAFLD is expected to increase in primary care settings. This entails a rising prevalence of the cardiovascular events associated with NAFLD.

A rapid diagnosis of NAFLD, as well as an evaluation of liver fibrosis stage and risk is crucial to improving patient outcomes. Patients at high risk of NAFLD (those with comorbidities, with any detected hepatic steatosis, and with elevated plasma aminotransferases) should thus be screened promptly for NAFLD or advanced fibrosis. This screening should be conducted even if the patient presents normal liver biochemistry or an absence of NAFLD symptoms.

While liver biopsy is the “gold standard” for diagnosing NASH, its disadvantages linked to invasiveness mean that noninvasive tools (serum biomarkers and imaging) are undergoing more frequent use.

Current NAFLD management guidelines promote weight loss efforts through lifestyle changes, medications, and surgical interventions. However, NAFLD management relies heavily on the presence or absence of NASH fibrosis, a pivotal determinant of liver-related mortality. As such, if the stage of liver fibrosis is F3 or above, clinicians should shift their management plan and prioritise a much more aggressive treatment approach. This implies moving from lifestyle modification to aggressive management of comorbid conditions.

Currently, no pharmacologic agents have yet been approved for the treatment of NAFLD or NASH in the US or Europe. However, considerable clinical trial efforts are currently underway.

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Dr. S Duarte

Dr. S Duarte

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