What is the treatment for fatty liver disease?

Treatment for Fatty Liver Disease

The primary treatment for fatty liver disease is lifestyle modification targeting a 7-10% weight loss through a combination of caloric restriction and regular physical activity. 1 This approach has been shown to produce near universal resolution of non-alcoholic steatohepatitis (NASH) and improvement in fibrosis by at least one stage with weight reductions of ≥10%, while even modest weight loss (>5%) can produce important benefits. 1, 2

Risk Assessment and Diagnosis

Before initiating treatment, assess the severity of fatty liver disease:

• Use the FIB-4 index to assess risk of advanced fibrosis:

  • Low risk: <1.3
  • Indeterminate risk: 1.3-2.67
  • High risk: >2.67 1

• For indeterminate or high FIB-4 scores, use transient elastography (FibroScan):

  • Low risk: <8 kPa
  • Indeterminate risk: 8-12 kPa
  • High risk: >12 kPa 1

• Patients with discordant or indeterminate results should be referred to hepatology 1

• Patients with high NAFLD Fibrosis Score should be referred to a hepatologist for comprehensive evaluation, including liver biopsy 1

Lifestyle Modifications

Dietary Recommendations

• Caloric restriction: 500-1000 kcal energy deficit to induce weight loss of 500-1000g/week 1

• Mediterranean diet: Strongly recommended even without weight loss 1, 2

  • Daily consumption of vegetables and fresh fruits
  • Unsweetened cereals rich in fiber
  • Nuts, fish, white meat
  • Olive oil as principal source of fat
  • Minimal use of simple sugars and red/processed meats

• Increase:

  • Monounsaturated fats (MUFAs)
  • Polyunsaturated omega-3 fats (PUFAs)
  • Plant-based proteins and dietary fibers 1

• Avoid:

  • Fructose and sugar-sweetened beverages
  • Saturated fatty acids and trans fats 1

Physical Activity

• 150-300 minutes/week of moderate-intensity aerobic physical activity (brisk walking, stationary cycling) 1
• Resistance training is also effective and promotes musculoskeletal fitness 1
• Both aerobic exercise and resistance training effectively reduce liver fat 1
• Any increase in physical activity is better than continued inactivity 1

Pharmacotherapy

Pharmacotherapy should be considered for patients with biopsy-proven NASH or those who fail to respond to lifestyle modifications:

• Vitamin E (800 IU daily): Can be considered for non-diabetic patients with biopsy-proven NASH

  • Caution: Increased risk in patients with prostate cancer or at high risk for it 1, 3

• Pioglitazone (30 mg daily): Can be considered for patients with biopsy-confirmed NASH, with or without diabetes

  • Improves insulin sensitivity and reduces hepatic fat content
  • Side effects: Weight gain, edema, and increased risk of fractures 1, 4, 3

• Emerging therapies: GLP-1 receptor agonists (semaglutide, liraglutide) and SGLT2 inhibitors show promise but require further investigation 1, 4, 3

• Medications to avoid: Corticosteroids, amiodarone, methotrexate, tamoxifen, estrogens, tetracyclines, and valproic acid as they may worsen steatosis 1

Management of Metabolic Risk Factors

• Aggressively manage metabolic risk factors:

  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Cardiovascular disease 1

• Limit alcohol consumption to no more than 1 drink/day for women and 2 drinks/day for men 1

Monitoring and Follow-up

• Regular liver function tests every 3-6 months

• Repeat imaging in 6-12 months

• Reassessment of fibrosis markers in 1-2 years 1

• Consider liver biopsy when:

  • Patient has risk factors for NASH and advanced fibrosis
  • Findings concerning for cirrhosis
  • Undergoing cholecystectomy or bariatric surgery and intraoperative biopsy is low risk
  • NASH or advanced liver fibrosis is suspected
  • Concurrent other chronic liver diseases cannot be excluded 1

• Hepatocellular carcinoma (HCC) surveillance every 6 months for patients with cirrhosis 1

Bariatric Surgery

For patients with obesity and NAFLD who fail to respond to lifestyle modifications, bariatric surgery can be considered:

• Results in significant weight loss and can lead to NASH resolution in up to 80% of subjects at 1-year follow-up 5
• Improves liver fat content, inflammation, and potentially fibrosis 3

Common Pitfalls and Caveats

• Unrealistic weight loss goals: Setting gradual, achievable targets (<1 kg/week) is important to avoid worsening portal inflammation 1

• Inadequate follow-up: Regular monitoring is essential to assess response to treatment and disease progression 1

• Overlooking metabolic comorbidities: Treating NAFLD in isolation without addressing diabetes, hypertension, and dyslipidemia is insufficient 1

• Relying solely on medications: Pharmacotherapy should complement, not replace, lifestyle modifications 2, 4

• Inconsistent physical activity: Both aerobic and resistance exercises are beneficial, but consistency is key 1