What are the management options for fatty liver disease?

Management of Fatty Liver Disease

Lifestyle modifications including weight reduction, dietary control, and exercise are the cornerstone treatments for all patients with nonalcoholic fatty liver disease (NAFLD), regardless of the degree of inflammation or fibrosis. 1

Assessment and Diagnosis

• NAFLD encompasses a spectrum from simple steatosis to nonalcoholic steatohepatitis (NASH) and cirrhosis
• Liver biopsy should be considered in patients with:
  • Suspected NAFLD with competing etiologies for hepatic steatosis
  • Co-existing chronic liver diseases that cannot be excluded without biopsy 1
  • Increased risk of steatohepatitis and advanced fibrosis 2

Treatment Approach

Weight Loss

• Weight loss is crucial for all NAFLD patients, regardless of obesity status 1
• Target weight loss goals:
  • 3-5% weight loss: Improves steatosis 1
  • 5-7% weight loss: Decreases intrahepatic fat content and inflammation 1
  • 7-10% weight loss: Required for histologic improvement including fibrosis regression 1, 2, 3
  • Weight loss >10% resulted in fibrosis improvement in 45% of patients 1

Dietary Recommendations

• Reduce total energy intake by approximately 500 kcal/day 1, 2
• Recommended daily intake:
  • Men: 1,500-1,800 kcal/day
  • Women: 1,200-1,500 kcal/day 1
• Dietary composition:
  • Low-carbohydrate and low-fructose diet 2
  • Increase monounsaturated fats (MUFAs) and polyunsaturated omega-3 fats (PUFAs)
  • Increase plant-based proteins and dietary fibers
  • Avoid fructose, sugar-sweetened beverages, saturated fatty acids, and trans fats 2
• Mediterranean diet pattern is beneficial 4

Exercise Recommendations

• At least moderate-intensity exercise for more than 30 minutes, more than 3 times per week 1
• Regular physical activity of 150-300 minutes/week of moderate-intensity exercise 2
• Both aerobic and resistance exercise similarly reduce liver fat content 1
• Exercise alone can reduce hepatic steatosis even without significant weight loss 1, 5

Rate of Weight Loss

• Progressive weight loss of less than 1 kg/week is recommended 1, 2
• Rapid weight loss (>1.6 kg/week) may worsen portal inflammation and fibrosis 1

Pharmacological Treatment

Pharmacological treatments should be limited to patients with biopsy-proven NASH and fibrosis 1:

1. Vitamin E (800 IU/day):

   • Consider for non-diabetic NASH patients without cirrhosis 2
   • Improves liver histology but has safety concerns with long-term use

2. Pioglitazone (30 mg/day):

   • Can be used for NASH treatment in patients with or without diabetes 2
   • Improves liver enzymes, reduces hepatic fat accumulation and inflammation

3. GLP-1 receptor agonists:

   • May be beneficial in NASH patients, especially those with diabetes 2, 6
   • Improve cardiometabolic profile and can reverse steatosis

4. SGLT2 inhibitors:

   • Consider for glucose control in patients with diabetes 2

Monitoring

• Regular liver function tests every 3-6 months
• Imaging exams every 6-12 months
• Risk stratification using:
  • FIB-4 index: <1.3 (low risk), 1.3-2.67 (indeterminate), >2.67 (high risk)
  • FibroScan: <8 kPa (low risk), 8-12 kPa (indeterminate), >12 kPa (high risk) 2

Special Considerations

• Alcohol use: Complete abstinence is recommended for patients with advanced fibrosis or cirrhosis 2
• Sarcopenia: Nutritional consultation is strongly recommended 2
• Bariatric surgery: Consider for obese patients with NAFLD/NASH if otherwise indicated 2, 7
• Comorbidities: Treat associated conditions (diabetes, dyslipidemia, hypertension) according to standard guidelines 1, 2

Pitfalls and Caveats

• Rapid weight loss (>1.6 kg/week) may worsen liver inflammation 1
• Pharmacological treatments should be limited to those with biopsy-proven NASH and fibrosis 1
• Ongoing surveillance is necessary for patients with cirrhosis who achieve fibrosis regression due to residual risk of hepatocellular carcinoma 2
• Exercise selection should consider individual preferences and cardiopulmonary fitness to ensure long-term adherence 1