What is the recommended management for a patient with fatty liver (non‑alcoholic fatty liver disease or alcoholic fatty liver)?

Management of Fatty Liver Disease

All patients with fatty liver disease require lifestyle modification targeting 7-10% weight loss through Mediterranean diet and 150-300 minutes weekly of moderate-intensity exercise, combined with aggressive management of cardiovascular risk factors including statins for dyslipidemia and standard antihypertensive therapy, as cardiovascular disease—not liver failure—is the primary cause of death before cirrhosis develops. 1

Risk Stratification Algorithm

Calculate FIB-4 score immediately to determine management pathway: 1

• FIB-4 <1.3 (Low Risk): Manage in primary care with lifestyle intervention only; no liver-specific pharmacotherapy needed 1
• FIB-4 1.3-2.67 (Intermediate Risk): Obtain liver stiffness measurement by transient elastography 1
  • LSM <8.0 kPa: Treat as low risk 1
  • LSM 8.0-12.0 kPa: Continue monitoring, aggressive lifestyle modification 1
  • LSM >12.0 kPa: Refer to hepatology 1
• FIB-4 >2.67 (High Risk): Immediate hepatology referral for multidisciplinary management 1, 2

Lifestyle Intervention Protocol (All Patients)

Weight Loss Strategy

Create a 500-1000 kcal/day caloric deficit to achieve 500-1000g weekly weight loss, targeting 7-10% total body weight reduction. 1 This approach achieves:

• 5% weight loss: Reduces steatosis 3
• 7% weight loss: Resolves steatohepatitis 3
• 10% weight loss: Regresses fibrosis 1, 3

Dietary Prescription

Prescribe Mediterranean diet as the primary dietary pattern: 1, 4

• Daily consumption of vegetables, fresh fruit, whole grains, legumes, nuts, fish or white meat 1
• Olive oil as primary fat source 1
• Minimal simple sugars, red meat, and processed meats 1
• Eliminate all fructose-containing beverages and commercially produced fructose foods 1, 4

Alcohol Restriction

Restrict alcohol to ≤20g/day for women and ≤30g/day for men, or complete abstinence in advanced fibrosis. 1 Even 9-20g daily alcohol doubles the risk of adverse liver outcomes in NAFLD patients. 1

Exercise Prescription

Prescribe 150-300 minutes weekly of moderate-intensity aerobic exercise (brisk walking, cycling) distributed over 3-5 sessions. 1, 4 Add resistance training on ≥2 days weekly, which provides independent benefits on liver fat and is particularly suitable for patients with poor cardiorespiratory fitness. 1, 4, 3 Exercise reduces hepatic fat even without weight loss by improving insulin sensitivity. 4, 5

Cardiovascular Risk Management (All Patients)

Lipid Management

Prescribe statins for all patients with 10-year cardiovascular risk ≥10% by QRISK3 or those with diabetes, regardless of liver disease severity. 1, 4 Statins are safe in compensated cirrhosis and associated with 37% reduction in hepatocellular carcinoma risk and 46% reduction in hepatic decompensation. 1, 2, 4 Hepatotoxicity is extremely rare and benefits vastly outweigh risks. 1, 4

Hypertension Management

Target blood pressure <130/85 mmHg using standard antihypertensive guidelines. 1, 3 NAFLD increases hypertension risk 3-fold, creating synergistic acceleration of cardiovascular disease. 3

Diabetes Management

For diabetic patients, prioritize GLP-1 receptor agonists as first-line glucose-lowering agents. 2 Liraglutide achieved 39% NASH resolution versus 9% placebo in clinical trials. 1, 2 Pioglitazone is an alternative for patients unable to tolerate or afford GLP-1 agonists. 2

Pharmacotherapy for Advanced Disease

Patients with Biopsy-Proven NASH and Significant Fibrosis (F2-F3)

Consider vitamin E 800 IU daily for non-diabetic patients with biopsy-proven NASH without cirrhosis. 1, 2 Evidence is mixed in diabetic patients. 2

Consider pioglitazone for diabetic patients with biopsy-proven NASH, which achieved 47% steatohepatitis resolution in trials. 2 However, counsel patients about weight gain and bone fracture risks. 1

Patients with Cirrhosis (F4)

Refer to hepatology for multidisciplinary management including: 1, 4

• Abdominal ultrasound every 6 months for hepatocellular carcinoma screening 1, 2, 4
• Esophagogastroduodenoscopy for variceal screening 1, 4
• Transplant evaluation if decompensation occurs (ascites, encephalopathy, variceal bleeding, jaundice) 1, 4

Medications to Discontinue

Stop hepatotoxic medications that worsen steatosis: corticosteroids, amiodarone, methotrexate, tamoxifen, estrogens, tetracyclines, valproic acid. 1, 4

Monitoring Schedule

Low-risk patients (FIB-4 <1.3): Annual FIB-4 reassessment in primary care 1

Intermediate-risk patients: Repeat liver stiffness measurement every 1-2 years 1

High-risk patients: Hepatology follow-up every 6-12 months with HCC surveillance if cirrhosis present 1, 2, 4

Critical Pitfalls to Avoid

Do not withhold statins due to unfounded hepatotoxicity concerns—they are safe and life-saving in NAFLD patients. 1, 4, 3

Do not recommend rapid weight loss >1kg/week—this may paradoxically worsen liver inflammation. 4

Do not use metformin as NAFLD-specific therapy—it has no significant effect on liver histology despite glycemic benefits. 4

Do not focus solely on liver disease while neglecting cardiovascular risk—cardiovascular disease causes the majority of deaths in NAFLD patients before cirrhosis develops. 1, 3