Treatment of Grade 1 Steatohepatitis
The cornerstone of treatment for grade 1 steatohepatitis is lifestyle modification focused on weight loss through a Mediterranean diet and structured exercise program, with a target of 7-10% weight reduction to improve liver histology. 1, 2
Lifestyle Modifications
Dietary Recommendations
- Mediterranean diet has the strongest evidence for improving liver and cardiometabolic health 1, 2
- Implement a hypocaloric diet with:
- 500-1000 kcal daily reduction from baseline
- Daily caloric intake of 1200-1500 kcal
- Gradual weight loss of up to 1 kg/week
- Reduce macronutrient content by:
- Limiting saturated fat
- Reducing starch and added sugar
- Replacing saturated fats with monounsaturated and polyunsaturated fatty acids
- Using extra virgin olive oil as the primary fat source
Exercise Recommendations
- Both aerobic and resistance training improve steatohepatitis 1
- Aim for at least 150-200 minutes/week of moderate-intensity activity
- Divide exercise into 3-5 sessions per week
- Exercise intensity should be proportional to treatment engagement 1
Weight Loss Targets
- 3-5% weight loss: Improves steatosis
- 7-10% weight loss: Improves liver inflammation, ballooning injury, and biochemistry 3
- >10% weight loss: Improves fibrosis 3
Weight reduction is strongly correlated with improvement in NASH histological activity score (NAS), with significant improvements in steatosis, lobular inflammation, and ballooning injury in patients who achieve ≥7% weight loss 3.
Pharmacological Options
Currently, there are no FDA-approved medications specifically for steatohepatitis 1, 2. However, certain medications may be considered:
For Patients with Type 2 Diabetes and Steatohepatitis
Pioglitazone has demonstrated efficacy in reversing steatohepatitis in patients with prediabetes or type 2 diabetes 1
- Improves glucose and lipid metabolism
- May slow fibrosis progression
- Has been shown to resolve NASH in 47% of patients compared to 21% in placebo groups 1
GLP-1 receptor agonists (particularly semaglutide) 1, 2
- Consider as adjunctive therapy to lifestyle interventions
- Beneficial for weight loss and may improve steatohepatitis
- Safe in patients with compensated cirrhosis
For Non-Diabetic Patients
- Vitamin E (800 IU/day) may be considered for non-diabetic adults with biopsy-proven NASH 1
- Improves steatosis in patients without diabetes
- Limited evidence for efficacy in patients with diabetes
Monitoring and Follow-up
- Monitor liver enzymes every 3 months
- Repeat imaging at 6-12 months
- Consider liver biopsy after 1-2 years of therapy to assess histological response
- Use non-invasive fibrosis assessment (e.g., FibroScan, FIB-4) every 1-2 years to monitor for disease progression
Bariatric Surgery
Consider bariatric surgery for patients with obesity who fail to achieve adequate weight loss through lifestyle modifications 2, 4. Surgical weight loss has been shown to improve:
- Hepatic steatosis
- Steatohepatitis
- Potentially hepatic fibrosis
Common Pitfalls and Caveats
Underestimating the importance of weight loss: Many clinicians focus on medications while neglecting the fundamental role of weight loss in treating steatohepatitis.
Setting unrealistic weight loss goals: Gradual, sustained weight loss is more effective and safer than rapid weight loss.
Overlooking cardiovascular risk: Patients with steatohepatitis are at increased cardiovascular risk and require comprehensive management of cardiovascular risk factors 1.
Assuming all medications for diabetes will help steatohepatitis: While pioglitazone and GLP-1 receptor agonists have evidence for benefit, metformin has not shown efficacy in treating steatohepatitis despite being first-line therapy for diabetes 1.
Discontinuing statins unnecessarily: Statin therapy is safe in adults with steatohepatitis, including those with compensated cirrhosis, and should be continued for cardiovascular risk reduction as clinically indicated 1.