From the Guidelines
Treatment options for Non-Alcoholic Steatohepatitis (NASH) should primarily focus on lifestyle modifications, with a goal of losing 7-10% of body weight to significantly improve liver histology, as recommended by the most recent guidelines 1. The cornerstone of treatment is weight loss through diet and exercise, with a Mediterranean diet (rich in olive oil, nuts, fruits, vegetables, and fish) combined with regular physical activity (150 minutes of moderate exercise weekly) showing the most benefit 1. For diabetic patients with NASH, medications like pioglitazone (15-45 mg daily) and GLP-1 receptor agonists such as semaglutide have demonstrated improvement in liver histology 1. Some studies suggest that Vitamin E (800 IU daily) may benefit non-diabetic patients with biopsy-proven NASH 1. However, the most recent and highest quality study, published in 2024, recommends a stepwise approach using blood-based scores and imaging techniques to rule-out/in advanced fibrosis, and advises lifestyle modification, optimal management of comorbidities, and consideration of bariatric surgery for individuals with MASLD and obesity 1. Key aspects of treatment include:
- Lifestyle modification, including weight loss, dietary changes, and physical exercise
- Optimal management of comorbidities, such as type 2 diabetes and obesity
- Consideration of bariatric surgery for individuals with MASLD and obesity
- Use of incretin-based therapies, such as semaglutide, for type 2 diabetes or obesity, if indicated
- Management of MASH-related cirrhosis, including adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, and liver transplantation in decompensated cirrhosis. It is essential to prioritize the management of comorbidities like diabetes, hypertension, and dyslipidemia, as these conditions can worsen liver disease, and patients with advanced fibrosis or cirrhosis require regular monitoring for complications and may ultimately need liver transplantation 1.
From the Research
Treatment Options for Non-Alcoholic Steatohepatitis (NASH)
The treatment options for NASH include:
- Lifestyle modification, which remains the primary recommendation for the treatment of NASH, although such changes are difficult to sustain and may be insufficient to cure NASH 2
- Bariatric surgery, which is recommended for morbidly obese patients with NASH, as it can resolve NASH in patients where lifestyle modifications have failed 2
- Pharmacotherapies, such as vitamin E and pioglitazone, which are recommended in patients with NASH, although concerns about their side effects remain 2, 3
- Emerging therapies, including agents targeting various vital molecules and pathways, such as metabolic perturbations, inflammatory cascades, and oxidative stress, which are in clinical trials for the treatment of NASH 2, 4
Current Management of NASH
The current management of NASH involves:
- Limiting energy surplus alone, or in combination with targeting of downstream pathways of inflammation and fibrosis 5
- Managing associated comorbidities, such as diabetes, hypertension, dyslipidaemia, and cardiovascular diseases 5
- Screening for hepatocellular carcinoma and extrahepatic malignancies in patients with NASH 5
Pharmacological Treatment Options
Pharmacological treatment options for NASH include:
- Vitamin E and pioglitazone, which are considered by current international guidelines 4
- GLP-1 agonists, FXR and PPAR ligands, and other agents, which have shown promise in randomized controlled trials and may expand the therapeutic armamentarium for NAFLD in the near future 4
Novel Therapeutic Approaches
Novel therapeutic approaches for NASH include: