What are the treatment options for liver steatosis?

Treatment Options for Liver Steatosis

The most effective treatment for liver steatosis is lifestyle modification with a focus on sustained weight loss of ≥5% to reduce liver fat, 7-10% to improve liver inflammation, and ≥10% to improve fibrosis. 1, 2

Lifestyle Interventions

Diet

• A Mediterranean dietary pattern should be adopted, limiting ultra-processed foods rich in sugars and saturated fats, and avoiding sugar-sweetened beverages 1, 2
• Implement a hypocaloric diet with 500-1000 kcal energy deficit to achieve weight loss of 500-1000g/week 2, 3
• Avoid fructose-containing beverages and foods which can worsen steatosis 2
• Limit or avoid alcohol consumption (no more than 1 drink/day for women, 2 drinks/day for men, or consider complete abstinence) 1, 3

Physical Activity

• Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous-intensity physical activity, tailored to individual preference and ability 1, 2, 3
• Combined exercise and diet interventions produce greater improvements in liver enzymes and insulin resistance than either intervention alone 4
• High-intensity interval training may be particularly effective for reducing cortisol levels associated with hepatic fat accumulation 5

Risk Stratification and Monitoring

Assessment

• Use non-invasive tests like FIB-4 score, liver stiffness measurement (LSM), or NAFLD Fibrosis Score to identify patients at risk for advanced fibrosis 2, 3
• Risk stratification categories:
  • Low risk: FIB-4 <1.3, LSM <8.0 kPa, or liver biopsy fibrosis stage F0-F1 2, 3
  • Intermediate risk: FIB-4 1.3-2.67, LSM 8.0-12.0 kPa 3
  • High risk: FIB-4 >2.67, LSM >12.0 kPa 3

Monitoring

• Non-invasive tests may be repeatedly used to assess fibrosis progression but provide limited information about treatment response 1
• Low-risk patients should have annual follow-up with repeated non-invasive tests 3
• Intermediate and high-risk patients should have more frequent monitoring (every 6 months) 3
• Liver biopsy is not suited for routine monitoring due to invasiveness but may be used in individual cases to assess treatment response 1

Management of Comorbidities

• A multidisciplinary approach is recommended to address all components of metabolic syndrome 1, 2, 3
• Optimize management of diabetes, dyslipidemia, and hypertension 1, 3
• Consider incretin-based weight loss drugs (e.g., semaglutide, tirzepatide) for patients with type 2 diabetes or obesity 1
• Statins are safe and effective for managing dyslipidemia in patients with fatty liver disease 3
• Discontinue medications that may worsen steatosis: corticosteroids, amiodarone, methotrexate, tamoxifen, estrogens, tetracyclines, valproic acid 1, 3

Bariatric Surgery

• Consider bariatric procedures for patients with class II or III obesity who have not achieved adequate weight loss through lifestyle modifications 1
• Bariatric surgery is an option for individuals with liver steatosis and obesity 1

Common Pitfalls to Avoid

• Neglecting cardiovascular risk assessment, as cardiovascular disease is the main driver of mortality in patients with non-alcoholic fatty liver disease before cirrhosis develops 3
• Failing to address all components of metabolic syndrome, which can worsen liver disease progression 3
• Relying solely on liver enzymes for diagnosis or monitoring, as they may be normal despite significant liver disease 2
• Overlooking the importance of sustained lifestyle changes, as short-term interventions rarely lead to long-term improvements 6, 7

Special Considerations

• For patients with advanced disease (MASH with significant fibrosis stage ≥2), consider referral to hepatology for specialized management and potential pharmacotherapy 1, 3
• Patients with cirrhosis require surveillance for portal hypertension and hepatocellular carcinoma 1
• Antioxidant supplementation (e.g., vitamin E, silymarin) may provide additional benefits as adjuncts to lifestyle modifications 8