What is the recommended treatment for fatty liver disease?

Treatment for Fatty Liver Disease

The cornerstone of fatty liver disease treatment is lifestyle modification focused on weight loss of 7-10% through caloric restriction and regular physical activity, which has been shown to improve liver histology, reduce inflammation, and even improve fibrosis. 1, 2

First-Line Treatment: Lifestyle Modifications

Weight Loss Goals

• Target weight loss of 7-10% in overweight/obese patients with fatty liver disease to improve liver histology, reduce steatosis, inflammation, and potentially reverse steatohepatitis 1, 2
• Even modest weight loss of 5% can significantly reduce intrahepatic fat content 1
• Aim for gradual weight loss of approximately 0.5-1 kg/week to avoid rapid weight reduction which may worsen liver disease 2

Dietary Recommendations

• Follow a Mediterranean diet pattern, which can reduce liver fat even without weight loss 1, 3
• Implement caloric restriction of 500-1000 kcal/day to achieve weight loss of 500-1000g/week 1
• Reduce carbohydrate intake, especially sugars and refined carbohydrates (40% of calories vs. 50-60% in typical low-fat diets) 2, 4
• Increase monounsaturated and omega-3 fatty acid intake (40% of calories as fat vs. up to 30% in typical low-fat diets) 2, 4
• Avoid processed foods and beverages with added fructose 1, 2
• Limit or avoid alcohol consumption, as it can exacerbate liver damage 1

Physical Activity Recommendations

• Engage in at least 150-300 minutes of moderate-intensity aerobic exercise per week or 75-150 minutes of vigorous-intensity exercise 1
• Include resistance training as a complement to aerobic exercise 1
• Note that any physical activity is better than none - even modest increases in activity can improve liver health 1
• Exercise alone, even without weight loss, can reduce hepatic fat content by improving insulin sensitivity 1, 3

Treatment Based on Disease Severity

For All Patients with Fatty Liver Disease

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

For Patients with NASH or Significant Fibrosis

• Continue aggressive lifestyle modifications 1, 2
• Consider pharmacological treatment in addition to lifestyle changes 1, 2
• Vitamin E (800 IU/day) may be considered for non-diabetic adults with biopsy-confirmed NASH 5, 2
• Pioglitazone (30 mg daily) may be effective for patients with biopsy-proven NASH with or without diabetes 2, 6
• Consider Resmetirom for non-cirrhotic NASH with significant fibrosis (stage ≥2) if locally approved 2
• Consider bariatric surgery for individuals with fatty liver disease and obesity 5, 2, 6
• For patients with diabetes, incretin-based therapies (e.g., semaglutide, tirzepatide) may be beneficial 2

Monitoring and Follow-up

• Use non-invasive tests like NAFLD Fibrosis Score to identify patients at risk for advanced fibrosis 1
• Reserve liver biopsy for patients who would benefit most from diagnostic, therapeutic guidance, and prognostic perspectives 1
• Monitor for cardiovascular disease, which is the main driver of morbidity and mortality in fatty liver disease patients before the development of cirrhosis 1
• For patients with known cirrhosis, perform right upper quadrant ultrasound every 6 months for HCC screening 1

Common Pitfalls and Caveats

• Avoid rapid weight loss (>1kg/week) as it may worsen liver disease 1, 2
• Focus on sustainability - choose dietary and exercise regimens that can be maintained long-term 1
• No specific pharmacotherapy has been universally approved by regulatory agencies specifically for fatty liver disease treatment 1
• Metformin is not recommended as a specific treatment for fatty liver disease as it has no significant effect on liver histology 1
• Discontinue medications that may worsen steatosis when possible, such as corticosteroids, amiodarone, methotrexate, tamoxifen, estrogens, tetracyclines, and valproic acid 1