What are the treatment options for hepatic steatosis?

Treatment Options for Hepatic Steatosis

The cornerstone of treatment for hepatic steatosis is lifestyle modification, including weight loss of 5-10% of body weight, adherence to a Mediterranean diet pattern, and regular physical activity of 150-300 minutes per week. 1, 2

Understanding Hepatic Steatosis

Hepatic steatosis, now termed Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) or previously Non-Alcoholic Fatty Liver Disease (NAFLD), is defined as excess fat accumulation in the liver (≥5% of liver weight). It exists on a spectrum from:

• Simple steatosis
• Steatohepatitis (MASH, previously NASH)
• Fibrosis
• Cirrhosis
• Hepatocellular carcinoma

First-Line Treatment: Lifestyle Modifications

Weight Loss Goals

• 5% weight reduction: Improves hepatic steatosis
• 7-10% weight reduction: Improves inflammation (steatohepatitis)

• 10% weight reduction: Improves fibrosis 2, 1

Dietary Recommendations

1. Mediterranean diet pattern 2, 1:

   • Daily consumption of vegetables and fresh fruits
   • Fiber-rich whole grains
   • Nuts and seeds
   • Fish and white meat
   • Olive oil as primary fat source
   • Limited red and processed meats
   • Minimal simple sugars

2. Specific dietary restrictions 2, 1:

   • Avoid ultra-processed foods
   • Limit sugar-sweetened beverages
   • Replace saturated fats with unsaturated fats
   • Limit excess fructose consumption

Physical Activity

• 150-300 minutes/week of moderate-intensity exercise OR
• 75-150 minutes/week of vigorous-intensity exercise 2, 1
• Even without significant weight loss, exercise alone can reduce hepatic steatosis 1, 3

Alcohol Consumption

• Complete abstinence is recommended for patients with advanced fibrosis or cirrhosis
• Significant limitation for all other patients with hepatic steatosis
• Even low alcohol intake (9-20g daily) can double the risk of adverse liver outcomes 2, 1

Pharmacological Therapy

For Non-Cirrhotic MASH with Significant Fibrosis

• Resmetirom may be considered for adults with non-cirrhotic steatohepatitis and significant hepatic fibrosis (stage ≥2) if locally approved 2, 1

For Patients with Comorbidities

• GLP-1 receptor agonists (semaglutide, liraglutide) are not specifically for steatohepatitis but provide indirect hepatic benefits through weight loss in patients with obesity or type 2 diabetes 2, 1
• Pioglitazone is safe in adults with non-cirrhotic steatohepatitis but lacks robust demonstration of histological efficacy 1, 4
• Vitamin E is not recommended due to lack of robust histological efficacy evidence and potential long-term risks 1
• Metformin has no significant effect on liver histology 1
• SGLT2 inhibitors are safe but not specifically recommended for steatohepatitis 1

Bariatric Surgery

Bariatric surgery should be considered for patients with obesity and hepatic steatosis who have not responded adequately to lifestyle interventions 2, 1

Monitoring and Follow-up

1. Baseline assessment:

   • Liver enzymes (ALT, AST, bilirubin, alkaline phosphatase)
   • Complete blood count
   • Coagulation profile (INR)
   • Renal function 2

2. Follow-up monitoring:

   • Non-invasive tests (liver enzymes, imaging techniques)
   • Reevaluation after 3-6 months of lifestyle intervention 2, 1

3. Consider liver biopsy if:

   • Patient has risk factors for MASH and advanced fibrosis (diabetes, metabolic syndrome)
   • Findings concerning for cirrhosis (thrombocytopenia, AST>ALT, hypoalbuminemia) 2

Common Pitfalls to Avoid

1. Focusing only on liver enzymes - normal enzymes don't exclude significant liver disease
2. Ignoring cardiovascular risk - cardiovascular disease is the main driver of morbidity and mortality
3. Rapid weight loss - can potentially worsen liver inflammation; gradual, sustained weight loss is preferred
4. Inadequate follow-up - sustained adherence to lifestyle changes is critical for success 1
5. Recommending alcohol consumption - even light-moderate alcohol intake can worsen outcomes in patients with hepatic steatosis 2

Special Considerations

• For patients with sarcopenia or decompensated cirrhosis: high-protein diet and late-evening snack
• For patients with compensated cirrhosis and obesity: moderate weight reduction plus high-protein intake and physical activity 1

By implementing these evidence-based interventions, hepatic steatosis can be effectively managed, reducing the risk of progression to more severe forms of liver disease and associated complications.