From the Guidelines
Nonalcoholic steatohepatitis (NASH) is a serious condition that requires prompt diagnosis and treatment to prevent progression to cirrhosis and hepatocellular carcinoma, and the most effective treatment approach involves lifestyle modifications, including weight loss and exercise, as well as consideration of pharmacological interventions such as vitamin E and pioglitazone in select patients 1. The diagnosis of NASH is typically made based on liver biopsy findings, which show steatosis, ballooning, and lobular inflammation 1. Patients with suspected or known nonalcoholic fatty liver disease (NAFLD) and a high risk for NASH or advanced fibrosis should be referred for consideration of liver biopsy 1. Some key points to consider in the management of NASH include:
- Lifestyle modifications, including weight loss and exercise, are the cornerstone of treatment and should be strongly encouraged 1
- Vitamin E and pioglitazone have been shown to benefit select patients with biopsy-proven NASH 1
- Statins and metformin therapy are not indicated for the treatment of NASH, but are safe and effective in NASH patients with other clinical indications for their use, such as dyslipidemia and diabetes 1
- A unified, international public health response to NAFLD and NASH is needed to address the growing epidemic of these conditions 1 It is essential to prioritize the management of NASH based on the most recent and highest-quality evidence, and to consider the potential benefits and risks of different treatment approaches in individual patients 1.
From the Research
Nash Treatment Options
- Vitamin E has been shown to have a beneficial effect on nonalcoholic fatty liver disease (NAFLD), including nonalcoholic steatohepatitis (NASH) 2
- Lifestyle changes, including daily exercise and diet, are also effective in the treatment of NAFLD/NASH, with combined exercise and diet showing greater reductions in liver enzymes and HOMA-IR compared to diet or exercise alone 3
- Vitamin E supplementation may improve clinical outcomes in patients with NASH and bridging fibrosis or cirrhosis, and is considered the first-line pharmacotherapy for NASH by global academic societies 4
Lifestyle Modifications
- Weight loss through lifestyle modification has been shown to significantly reduce features of NASH, with a greater extent of weight loss associated with a higher level of improvement in histologic features of NASH 5
- A weight loss of 7-10% has been shown to result in significant reductions in NAS scores, while a weight loss of ≥10% has been associated with the highest rates of NAS reduction, NASH resolution, and fibrosis regression 5
Pharmacological Treatments
- Pioglitazone, an insulin-sensitizing agent, has been shown to improve biochemical and histological features of NASH in a pilot study, although long-term safety and benefits require further study 6
- No pharmacotherapies for NASH have been approved, although vitamin E is considered a first-line treatment by some global academic societies 4