What are the guidelines for managing fatty liver disease?

Management Guidelines for Non-Alcoholic Fatty Liver Disease (NAFLD)

The cornerstone of NAFLD management is lifestyle modification with a target of 7-10% weight loss through a Mediterranean diet pattern and regular physical activity, which can improve steatosis, inflammation, hepatocyte ballooning, and even fibrosis. 1

Risk Assessment and Stratification

• Use 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

Dietary Interventions

• Mediterranean diet pattern is recommended, focusing on:

  • Increased: vegetables, fruits, fiber-rich cereals, nuts, fish, white meat, olive oil
  • Decreased: simple sugars, red/processed meats, saturated fats, trans fats 1

• For Korean and high-carbohydrate diet populations:

  • Low-carbohydrate dietary training is more effective than low-fat dietary training 2

• Key dietary recommendations:

  • Complete avoidance of fructose and sugar-sweetened beverages 1
  • Increase monounsaturated fats (MUFAs), polyunsaturated omega-3 fats (PUFAs), and plant-based proteins and dietary fibers 1
  • Daily caloric deficit of 500-1000 kcal to achieve weight loss of 500-1000g/week 1

Physical Activity Guidelines

• Exercise for at least 30 minutes twice per week can reduce liver fat 2
• Optimal recommendation: 150-300 minutes/week of moderate-intensity aerobic physical activity 1
• Both aerobic and resistance exercise are effective:
  • Aerobic exercise: walking, running, swimming, cycling at moderate intensity (50-70% of maximal heart rate) 2
  • Resistance exercise: beneficial for patients with poor cardiorespiratory fitness 2

Pharmacotherapy

• Currently, no medications are specifically approved for NAFLD treatment 1
• For non-diabetic patients with biopsy-proven NASH:
  • Vitamin E (800 IU/day) may be considered, with caution in patients with prostate cancer risk 1
• For patients with biopsy-confirmed NASH (with or without diabetes):
  • Pioglitazone (30mg daily) may be considered, with monitoring for weight gain, edema, and fracture risk 1
• For patients with NAFLD and type 2 diabetes:
  • GLP-1 receptor agonists and SGLT2 inhibitors should be considered as they promote weight loss and reduce cardiovascular risk 2, 1

Bariatric Surgery

• Consider referral for bariatric surgery for patients with obesity who meet eligibility criteria 1
• Particularly beneficial for patients with clinically significant fibrosis and obesity with comorbidities 1

Management of Metabolic Comorbidities

• Aggressively manage metabolic risk factors:
  • Hypertension: according to standard guidelines
  • Dyslipidemia: statin treatment for patients at increased cardiovascular risk
  • Diabetes: prioritize glucose-lowering agents that promote weight loss 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
• HCC surveillance every 6 months for patients with cirrhosis 1

Common Pitfalls and Caveats

1. Don't withhold statins from NAFLD patients, including those with compensated cirrhosis, due to unfounded concerns about hepatotoxicity 1

2. Avoid medications that may worsen steatosis:

   • Corticosteroids, amiodarone, methotrexate, tamoxifen, estrogens, tetracyclines, and valproic acid 1

3. Don't rely solely on initial assessment - NAFLD can progress over time, especially with development of additional risk factors like T2DM 2

4. Don't underestimate the importance of exercise - any increase in physical activity is better than continued inactivity 1

5. Recognize that different populations may respond differently to dietary interventions - Korean patients showed better response to low-carbohydrate diets compared to low-fat diets 2