How can I manage a patient with hepatic steatosis (fatty liver disease)?

From the Guidelines

To effectively manage a patient with hepatic steatosis, prioritize lifestyle modifications, including a hypocaloric diet and regular physical activity, as the cornerstone of treatment, as recommended by the most recent guidelines 1. The management of hepatic steatosis, also known as fatty liver disease, requires a comprehensive approach that focuses on reducing liver fat, inflammation, and fibrosis, while also addressing associated metabolic disorders.

Key Recommendations

• Lifestyle modification: Encourage patients to adopt a Mediterranean-style diet, rich in fruits, vegetables, whole grains, lean proteins, and healthy fats like olive oil, and to minimize saturated fatty acid intake and limit or eliminate consumption of commercially produced fructose 1.
• Weight loss: Aim for a weight loss of 5-10% of total body weight to decrease hepatic steatosis and improve nonalcoholic steatohepatitis, with a hypocaloric diet targeting 1200-1500 kcal/d or a reduction of 500-1000 kcal/d from baseline 1.
• Physical activity: Recommend regular physical activity, with a target of 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity aerobic exercise per week, and consider resistance training exercise as a complementary approach 1.
• Alcohol abstinence: Advise complete alcohol abstinence, as even moderate consumption can worsen fatty liver disease 1.
• Management of comorbidities: Optimize management of comorbidities, such as type 2 diabetes, obesity, hypertension, dyslipidemia, and cardiovascular disease, using appropriate medications and monitoring 1.
• Monitoring and follow-up: Monitor liver enzymes every 3-6 months and consider follow-up imaging after 6-12 months of intervention to assess the effectiveness of treatment 1.

Additional Considerations

• Bariatric surgery: Consider bariatric surgery as an option for individuals with hepatic steatosis and obesity, as it can lead to significant weight loss and improvement in metabolic disorders 1.
• Pharmacological treatment: For adults with non-cirrhotic metabolic dysfunction-associated steatohepatitis (MASH) and significant liver fibrosis, consider treatment with resmetirom, which has demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile 1.
• Nutritional counseling: Provide nutritional counseling to patients with MASH-related cirrhosis, and consider adaptations of metabolic drugs, surveillance for portal hypertension, and hepatocellular carcinoma, as well as liver transplantation in decompensated cirrhosis 1.

From the Research

Management of Hepatic Steatosis

To manage a patient with hepatic steatosis (fatty liver disease), the following approaches can be considered:

• Lifestyle modifications, including weight loss, daily exercise, and a healthy diet, as these have been shown to improve steatosis, inflammation, hepatocyte ballooning, and fibrosis 2, 3, 4
• A combination of diet and exercise appears to be more effective than either intervention alone in improving liver enzymes and insulin resistance 2
• Physical activity, including aerobic exercise and resistance training, can reduce hepatic fat independent of weight reduction and may prevent the development of non-alcoholic fatty liver disease 4

Pharmacological Approaches

While there are no approved pharmacological treatments for non-alcoholic fatty liver disease, some drugs have shown promise in improving liver histology, including:

• Pioglitazone and vitamin E, which have provided consistent benefits on liver histology and are recommended by European and American guidelines 5
• Statins, which have produced clinically meaningful results in patients with non-alcoholic fatty liver disease or non-alcoholic steatohepatitis 5
• Omega-3 polyunsaturated fatty acid substitution, which may decrease liver fat, although the optimal dose is not known yet 6

Diagnostic and Monitoring Tools

The following diagnostic and monitoring tools can be used to assess hepatic steatosis and non-alcoholic fatty liver disease:

• Liver biopsy, which remains the criterion standard for diagnosis 3
• Non-invasive tests, such as ultrasonography, computed tomography, and magnetic resonance imaging, which can assess hepatic fat and measure liver and spleen size 3, 6
• Controlled attenuation parameter, which can quantitatively assess hepatic fat content and differentiate between steatosis grades 6