What is the initial management for patients with hepatic steatosis?

Initial Management of Hepatic Steatosis

The primary treatment for hepatic steatosis should be lifestyle modifications focusing on weight loss of 7-10% through dietary changes and regular physical exercise, as this has been proven to improve liver histology and reduce liver fat. 1

Initial Assessment and Risk Stratification

1. Screening for other causes of liver disease:

   • Evaluate alcohol consumption using validated screening tools 2
   • Order liver function tests and complete blood count 2
   • Rule out other causes of steatosis (viral hepatitis, drug-induced, genetic disorders) 2

2. Fibrosis risk assessment:

   • Calculate FIB-4 score as first-line assessment 2
   • FIB-4 <1.3 (<2.0 in those >65 years) reliably excludes advanced fibrosis 2
   • For intermediate/high FIB-4 scores, proceed to second-tier testing with liver stiffness measurement (LSM) by transient elastography (FibroScan) 2

Management Algorithm

For Low-Risk Patients (FIB-4 <1.3 or LSM <8.0 kPa):

1. Lifestyle Interventions:

   • Diet:

     • Mediterranean dietary pattern with focus on vegetables, fruits, and fiber-rich foods 1
     • Limit saturated fats, commercially produced fructose, and added sugars 1
     • Minimum protein intake of 1.2-1.5 g/kg body weight 1
     • Consider consultation with a specialized nutritionist 1

   • Physical Activity:

     • 150-200 minutes/week of moderate-intensity aerobic activities in 3-5 sessions 1
     • Combine aerobic exercise with resistance training 1
     • Reduce sedentary behavior, especially TV sitting time 3

   • Weight Loss Targets:

     • 5% to reduce liver fat 1

     • 7-10% to improve liver inflammation 1

     • 10% for fibrosis improvement and potential NASH resolution 4

     • Target rate of weight loss <1 kg/week to avoid worsening portal inflammation 1

2. Management of Comorbidities:

   • Aggressive management of metabolic conditions (diabetes, hypertension, dyslipidemia) 1
   • Statins can be safely used in chronic liver disease, including compensated cirrhosis 1

3. Monitoring:

   • Liver enzymes every 3 months 1
   • Repeat imaging at 6-12 months 1
   • Non-invasive fibrosis assessment every 1-2 years 1

For Intermediate/High-Risk Patients (FIB-4 ≥1.3 or LSM ≥8.0 kPa):

1. All lifestyle interventions as above, plus:

2. Consider pharmacological therapy:

   • Resmetirom as first choice for non-cirrhotic MASLD with significant liver fibrosis (stage ≥2) 1
   • For patients with type 2 diabetes or obesity:
     • GLP-1 receptor agonists (semaglutide, liraglutide, dulaglutide) 1
     • SGLT2 inhibitors for patients with diabetes, heart failure, or chronic kidney disease 1

3. Consider bariatric surgery:

   • For patients with obesity meeting standard bariatric surgery criteria 1
   • Requires careful evaluation in patients with compensated cirrhosis 1

4. Specialist referral:

   • Patients with advanced fibrosis (F3-F4) should be managed by hepatology 2
   • Patients with discordant or indeterminate LSM results (8.0-12.0 kPa) should be referred to hepatology 2

5. Surveillance:

   • HCC surveillance with ultrasound every 6 months for patients with advanced fibrosis or cirrhosis 1

Common Pitfalls and Caveats

• Don't focus solely on steatosis: The mere presence of steatosis should not be the treatment target; focus on fibrosis risk and metabolic health 2
• Avoid rapid weight loss: Weight loss >1 kg/week can worsen portal inflammation and fibrosis 1
• Don't ignore comorbidities: Cardiovascular disease is the main driver of morbidity and mortality before cirrhosis develops 2
• Beware of medication restrictions in advanced disease:
  • Metformin is contraindicated in decompensated cirrhosis 1
  • Sulfonylureas should be avoided in hepatic decompensation 1
  • GLP-1 receptor agonists should be limited to Child-Pugh class A cirrhosis 1

By following this structured approach to hepatic steatosis management, clinicians can effectively address both liver-specific outcomes and the broader metabolic health of patients, potentially reversing disease progression and improving long-term outcomes.