From the Guidelines
Treatment for high-grade fatty liver (non-alcoholic steatohepatitis or NASH) should prioritize lifestyle modifications, including a hypocaloric diet and regular exercise, aiming for a 7-10% reduction in body weight, as recommended by the most recent and highest quality study 1.
Key Recommendations
- A Mediterranean diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats is recommended, while limiting processed foods, added sugars, and saturated fats 1.
- Regular physical activity of at least 150 minutes per week of moderate-intensity exercise is essential 1.
- Complete alcohol abstinence is strongly advised as it can worsen liver damage 1.
- For diabetic patients, medications like pioglitazone (15-30mg daily) or GLP-1 receptor agonists may help improve liver health while managing blood sugar, as suggested by a recent study 1.
- Vitamin E (800 IU daily) may benefit non-diabetic patients with biopsy-proven NASH, according to guidelines 1.
Lifestyle Modifications
- Weight loss of 5% of total body weight can decrease hepatic steatosis, weight loss of 7% of total body weight can lead to nonalcoholic steatohepatitis resolution, and weight loss of 10% of total body weight can result in fibrosis regression or stability 1.
- A hypocaloric diet targeting 1200–1500 kcal/d or a reduction of 500–1000 kcal/d from baseline is recommended 1.
- Regular physical activity, including aerobic and resistance training, can improve NAFLD and should be tailored to the individual's needs and abilities 1.
Medical Management
- Pioglitazone and GLP-1 receptor agonists have shown promise in improving liver health and managing blood sugar in diabetic patients with NASH 1.
- Vitamin E may be beneficial for non-diabetic patients with biopsy-proven NASH, but its use should be individualized and monitored closely 1.
Monitoring and Follow-up
- Regular monitoring with a healthcare provider is necessary to track improvement and adjust treatment as needed 1.
From the Research
High Grade Fatty Liver Treatment
- The mainstay of therapy for nonalcoholic fatty liver disease (NAFLD) remains weight loss through dietary modification and lifestyle change 2.
- Diet and lifestyle modification can improve liver fat content, nonalcoholic steatohepatitis (NASH), and fibrosis, with weight reductions of ≥10% inducing a near universal NASH resolution and fibrosis improvement by at least one stage 3.
- A Mediterranean diet, characterized by reduced carbohydrate intake and increased monounsaturated and omega-3 fatty acid intake, can reduce liver fat even without weight loss and is the most recommended dietary pattern for NAFLD 3.
Pharmacological Treatment Options
- Vitamin E may improve histology in NASH, but safety issues limit its use, and it can be considered in patients with biopsy-proven NASH without diabetes 2, 4.
- Pioglitazone improves liver histology, including fibrosis, and can be considered in patients with or without diabetes, with a significant reduction in fibrosis observed in patients with type 2 diabetes 2, 5, 4.
- Glucagon-like peptide-1 (GLP-1) antagonists may be beneficial in NASH, but more studies are needed before they can be recommended 4.
Emerging Therapies
- Novel agents specifically targeting NAFLD pathogenesis, including the farnesoid X receptor agonist obeticholic acid, have entered clinical trials and may expand the therapeutic armamentarium for NAFLD in the near future 2, 6.
- Bariatric surgery, with resultant weight loss, can result in improvement in liver fat and inflammation 4.