From the Guidelines
Treatment options for Non-Alcoholic Steatohepatitis (NASH) primarily focus on lifestyle modifications, with limited pharmaceutical interventions currently approved specifically for NASH. Weight loss through diet and exercise is the cornerstone of NASH treatment, with a goal of losing 7-10% of body weight to significantly improve liver histology, as supported by studies such as 1 and 1. A Mediterranean diet (rich in fruits, vegetables, whole grains, olive oil, and lean proteins) combined with regular physical activity (at least 150 minutes of moderate-intensity exercise weekly) has shown the most benefit, as indicated in 1 and 1. Some key points to consider in the management of NASH include:
- Lifestyle modification consisting of diet, exercise, and weight loss has been advocated to treat patients with NAFLD, with the best data demonstrating that overall weight loss is the key to improvement in the histopathological features of NASH, as shown in 1.
- Vitamin E (800 IU/day) may be considered for non-diabetic patients with biopsy-proven NASH, as it can reduce inflammation and liver cell injury, although its use is limited by potential side effects and lack of benefit on fibrosis, as discussed in 1 and 1.
- Pioglitazone (30-45 mg daily) can improve liver histology in both diabetic and non-diabetic patients with NASH but carries side effects including weight gain and increased fracture risk, as noted in 1 and 1.
- For NASH patients with type 2 diabetes, GLP-1 receptor agonists like semaglutide have shown promise in reducing liver inflammation and fibrosis, as reported in 1 and 1.
- Management of comorbidities such as diabetes, hypertension, and dyslipidemia is essential as these conditions can worsen NASH progression, as emphasized in 1 and 1.
- For patients with advanced fibrosis or cirrhosis due to NASH, liver transplantation may ultimately be necessary, as mentioned in 1 and 1. The effectiveness of these treatments stems from their ability to reduce insulin resistance, oxidative stress, and inflammation—key pathophysiological mechanisms in NASH development and progression, as discussed in 1, 1, 1, 1, and 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, 3
- Bariatric surgery, which is recommended for morbidly obese patients with NASH, as it can resolve NASH in patients where lifestyle modifications have failed 2, 3
- Pharmacotherapies, such as vitamin E and pioglitazone, which are recommended in patients with NASH, although concerns about their side effects remain 2, 4, 5
- Other agents targeting various vital molecules and pathways, including those impacting metabolic perturbations, inflammatory cascades, and oxidative stress, which are in clinical trials for the treatment of NASH 2
Role of Vitamin E in NASH Treatment
Vitamin E has been shown to:
- Improve transaminase activities and may resolve NASH histopathology without improving hepatic fibrosis 5
- Ameliorate NASH fibrosis, especially in patients with improved serum transaminase activities and insulin resistance 4
- Improve clinical outcomes in patients with NASH and bridging fibrosis or cirrhosis, including transplant-free survival and hepatic decompensation 6
- Be recommended as the first-line pharmacotherapy for NASH, according to the consensus of global academic societies 5
Other Considerations
- No NASH-specific therapies are approved by the US Food and Drug Administration, highlighting the need for further research and development of effective treatments 2, 3
- Early identification and targeted treatment of patients with NASH are needed to improve patient outcomes, including directing patients toward intensive lifestyle modification and referral for bariatric surgery as indicated 3