What are the treatment options for fatty liver disease?

Treatment Options for Fatty Liver Disease

Weight loss through lifestyle modifications is the cornerstone of treatment for fatty liver disease, with a target of 3-5% weight loss to improve steatosis and 7-10% to improve inflammation and fibrosis. 1, 2

Lifestyle Modifications

Dietary Interventions

• Implement caloric restriction of 500-1000 kcal/day to achieve weight loss of 500-1000g/week 2, 3
• Follow a Mediterranean diet pattern, which can reduce liver fat even without weight loss 2, 4
• Avoid fructose-containing beverages and foods, particularly important in younger lean patients 1, 3
• Limit alcohol consumption below risk threshold (30g for men, 20g for women) or consider complete abstinence 3
• Ensure gradual weight loss (maximum 1kg/week) as rapid weight loss may worsen liver inflammation and fibrosis 1, 3
• Consume a diet rich in monounsaturated fats (MUFAs), polyunsaturated fats (PUFAs), plant-based proteins, and dietary fibers 1
• Reduce intake of saturated fatty acids, trans-fats, simple sugars, and animal proteins 1

Physical Activity

• Engage in at least 150-300 minutes of moderate-intensity aerobic exercise per week 2, 5
• Include resistance training as a complement to aerobic exercise 2
• Recognize that any physical activity is better than none - even modest increases can improve liver health 2
• Exercise alone, even without weight loss, can reduce hepatic fat content by improving insulin sensitivity 2, 4

Treatment Based on Disease Severity

For All NAFLD Patients

• Implement lifestyle modifications (diet and exercise) regardless of disease severity 1, 2
• Treat comorbidities (diabetes, hypertension, dyslipidemia) 1, 2
• Monitor for disease progression with periodic non-invasive testing 2

For Patients with NASH or Fibrosis

• Continue aggressive lifestyle modifications with target weight loss of 7-10% 1, 2
• Consider pharmacological treatment in addition to lifestyle changes 1, 3
• Vitamin E (800 IU daily) may be considered for non-diabetic patients with biopsy-confirmed NASH without cirrhosis 1, 6
• Pioglitazone (30 mg daily) may be considered for patients with biopsy-confirmed NASH without cirrhosis 1, 6

For Patients with Cirrhosis

• Implement hepatocellular carcinoma surveillance with abdominal ultrasound with or without serum AFP twice per year 1, 3
• Consider referral to transplant center when appropriate 2
• Screen for esophageal varices 2

Special Considerations

For Lean NAFLD Patients

• Target modest weight loss of 3-5%, which has been found to be beneficial 1
• Limit fructose and sugar-sweetened beverages 1
• Focus on exercise, increasing physical activity, and decreasing visceral fat 1

For Patients with Sarcopenia

• Ensure minimum protein intake of 1.2–1.5 g/kg, with emphasis on branched-chain amino acids 1
• Encourage frequent small meals and avoid more than 4–6 hours between meals 1
• Consider a bedtime snack containing protein and at least 50g of complex carbohydrates 1
• Consult with a specialized nutritionist 1

Monitoring and Follow-up

• Use non-invasive tests like NAFLD Fibrosis Score to identify patients at risk for advanced fibrosis 2, 3
• Reserve liver biopsy for patients who would benefit most from diagnostic, therapeutic guidance, and prognostic perspectives 2
• Monitor for cardiovascular disease, which is the main driver of morbidity and mortality in NAFLD patients before the development of cirrhosis 2

Common Pitfalls and Caveats

• Avoid rapid weight loss (>1kg/week) as it may worsen liver disease 1, 2
• Choose sustainable dietary and exercise regimens that can be maintained long-term 2
• Be aware that no specific pharmacotherapy has been approved by regulatory agencies specifically for NAFLD treatment 2
• Recognize that metformin is not recommended as a specific treatment for NAFLD as it has no significant effect on liver histology 2, 3
• Understand that GLP-1 receptor agonists and SGLT2 inhibitors are promising but their role in NAFLD management is still being defined 1