From the Guidelines
The pharmacological treatment of non-alcoholic fatty liver disease (NAFLD) should prioritize pioglitazone (15-45 mg daily) for patients with biopsy-proven non-alcoholic steatohepatitis (NASH), as it improves insulin sensitivity and reduces liver inflammation, according to the most recent evidence 1. The treatment of NAFLD focuses on addressing metabolic risk factors and liver inflammation, with the goal of reducing the incidence and mortality of cardiovascular and liver-related complications.
- Key considerations in the management of NAFLD include:
- Lifestyle modifications such as weight reduction, dietary control, and exercise
- Treatment of comorbidities such as diabetes, obesity, hypertension, and dyslipidemia
- Pharmacologic treatments, including pioglitazone, vitamin E, and GLP-1 receptor agonists like semaglutide, which have shown promise in reducing liver fat and inflammation while promoting weight loss 1.
- The most recent evidence suggests that pioglitazone improves glucose and lipid metabolism and reverses steatohepatitis in people with prediabetes, type 2 diabetes, or even without diabetes 1.
- GLP-1 receptor agonists like semaglutide (starting at 0.25 mg weekly, increasing to 1-2.4 mg) are also recommended, as they have been shown to resolve steatohepatitis in 59% of patients with biopsy-proven NASH, compared to 17% in the placebo group 1.
- Vitamin E (800 IU daily) may be beneficial for non-diabetic patients with NASH, acting as an antioxidant to reduce oxidative stress in the liver, but its efficacy in patients with type 2 diabetes is less clear 1.
- Management of diabetes with metformin (500-2000 mg daily) may provide indirect benefits, and statins are generally safe and recommended for patients with dyslipidemia, despite elevated liver enzymes.
- Treatment should be individualized based on comorbidities, with regular monitoring of liver enzymes every 3-6 months to assess response and potential side effects.
From the Research
Pharmacological Treatment of Non-Specific Pain
- The pharmacological treatment of non-specific pain typically involves the use of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatment options 2.
- Topical NSAIDs are recommended for non-low back, musculoskeletal injuries 2.
- Acetaminophen is well tolerated, but lower doses should be used in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 2.
- Nonselective NSAIDs are effective, but should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 2.
Treatment of Acute Migraine
- Migraine-specific triptans and migraine-nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs) have the best levels of evidence and are recommended as first-line medications for acute migraine attacks 3, 4.
- Acetaminophen is suitable for mild to moderate migraine attacks and remains the first choice for children and pregnant women 3, 4.
- Opiates are not recommended for acute migraine treatment due to serious adverse events 3, 4.
- A combination of a triptan and a NSAID may yield better efficacy compared to either therapy alone 3.
Use of NSAIDs and Acetaminophen
- Chronic use of NSAIDs or acetaminophen was not associated with significant differences in mortality at 30 or 60 days among patients who tested positive for COVID-19 5.
- Ibuprofen is as highly regarded as other NSAIDs when used in similar circumstances, and switching patients to ibuprofen may be a realistic way of reducing financial and medical costs associated with NSAIDs 6.
- Patient-specific clinical features should help guide the selection of an acute medication for an individual patient 2, 4.