From the Guidelines
Hepatic steatosis should be managed with lifestyle modification, including weight loss, dietary changes, and physical exercise, as well as optimal management of comorbidities, such as type 2 diabetes or obesity, to prevent progression to more severe liver disease. According to the latest clinical practice guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD) 1, a stepwise approach using non-invasive tests, such as blood-based scores (e.g., fibrosis-4 index [FIB-4]) and imaging techniques (e.g., transient elastography), is recommended to rule out advanced fibrosis, which is predictive of liver-related outcomes.
Key aspects of management include:
- Weight loss, dietary changes, and physical exercise to improve insulin sensitivity and reduce liver fat
- Optimal management of comorbidities, such as type 2 diabetes or obesity, using incretin-based therapies (e.g., semaglutide, tirzepatide) if indicated
- Consideration of bariatric surgery in individuals with MASLD and obesity
- Potential use of resmetirom, a MASH-targeted treatment, in adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2), if locally approved and dependent on the label 1.
It is essential to note that no MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage, and management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counseling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis 1. Regular monitoring with liver function tests and imaging studies as needed is crucial to prevent long-term liver damage and progression to more severe liver disease.
From the Research
Hepatic Steatosis Treatment
- Hepatic steatosis, also known as non-alcoholic fatty liver disease (NAFLD), is a condition where excess fat accumulates in the liver cells [ 2, [ 3 ].
- The treatment of hepatic steatosis involves lifestyle modifications, such as weight loss and dietary changes, as well as pharmacological interventions [ 3, [ 4 ].
- Vitamin E and pioglitazone are two pharmacological agents that have been studied for their efficacy in treating hepatic steatosis [ 2, [ 4, [ 5, [ 6 ].
Pharmacological Interventions
- Vitamin E has been shown to improve liver histology, reduce steatosis, and decrease liver enzymes in patients with non-alcoholic steatohepatitis (NASH) [ 2, [ 5, [ 6 ].
- Pioglitazone, a thiazolidinedione, has been found to reduce steatosis, inflammation, and ballooning in patients with NASH, but its efficacy in improving fibrosis is unclear [ 2, [ 4, [ 5, [ 6 ].
- The combination of vitamin E and pioglitazone may be more effective than either agent alone in improving NASH histology [ 2, [ 4 ].
Comparison of Treatments
- A meta-analysis of randomized controlled trials found that vitamin E and thiazolidinediones (TZDs) improved liver histologic scores, but metformin did not [ 5 ].
- A clinical trial comparing pioglitazone, vitamin E, and placebo found that vitamin E was superior to placebo in improving NASH, while pioglitazone showed significant benefits in some secondary outcomes [ 6 ].
- Another systematic review found that pioglitazone and vitamin E are effective in reducing steatosis, inflammation, and ballooning, but there is conflicting data on fibrosis resolution [ 4 ].