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Thursday, October 23, 2014

Division of Diabetes Treatment and Prevention - Leading the effort to treat and prevent diabetes in American Indians and Alaska Natives


Standards of Care and Clinical Practice
Recommendations: Type 2 Diabetes

Last updated: July 2012

Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis

Clinical Practice Recommendations

Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis

recommendations icon Recommendations for Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH)

  • Check Aspartate Aminotransferase/Alanine Aminotransferase (AST/ALT) periodically in patients with diabetes.
  • For significant and persistent AST/ALT abnormalities, perform a workup to determine the cause.
  • Counsel patients with fatty liver disease regarding weight loss and exercise, and consider the use of medications shown to improve insulin resistance.

NAFLD and NASH represent a spectrum of diseases from simple fatty liver (steatosis) to steatosis with inflammation, necrosis, and cirrhosis. NAFLD occurs in people who drink little or no alcohol and affects all age groups. NASH represents the more severe end of this spectrum, and it is associated with liver disease that progresses to fibrosis and cirrhosis. The etiology of NASH and the cellular basis for fat accumulation in the liver are unclear. Most patients with NASH are obese and have associated type 2 diabetes, hypertension, dyslipidemia, and insulin resistance.

NAFLD or NASH diagnosis often is made during a workup of persistent AST/ALT elevations. Liver imaging studies with ultrasound or CT scan may show evidence of fat infiltration in the liver. Providers should rule out other causes of chronic liver disease (e.g., viral, autoimmune, etc.). Gastroenterology consultation is often indicated to assist with diagnosis, staging, and treatment of liver disease.

Treatment for both NAFLD and NASH includes weight loss, exercise, improved diabetes control, and lipid control. Glycemic control medications that reduce insulin resistance, such as metformin and thiazolidinediones (TZD), have been shown to improve serum AST/ALT and liver pathology through increasing insulin sensitivity.

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Resources

Tools for Clinicians and Educators

tools and resources icon Key Tools and Resources

National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health. Nonalcoholic Steatohepatitis Fact Sheet. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NIH Publication No. 07–4921. Updated 2012.

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Bibliography

Byrne CD. Non-alcoholic fatty liver disease, insulin resistance and ectopic fat: a new problem in diabetes management. Exit Disclaimer: You Are Leaving www.ihs.gov Diabet Med. 2012 Jun 4. doi: 10.1111/j.1464-5491.2012.03732.x. [Epub ahead of print].

McCarthy EM, Rinella ME. The role of diet and nutrient composition in nonalcoholic fatty liver disease. Exit Disclaimer: You Are Leaving www.ihs.gov J Acad Nutr Diet. 2012 Mar;112(3):401-9. Epub 2012 Mar 1.

Medina J, Fernández-Salazar LI, García-Buey L, Moreno-Otero R. Approach to the pathogenesis and treatment of nonalcoholic steatohepatitis. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2004;27(8):2057-66.

Tolman KG, Fonseca V, Dalpiaz A, Tan MH. Spectrum of liver disease in type 2 diabetes and management of patients with diabetes and liver disease: review. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2007 Mar;30(3):734-43.

Vuppalanchi R, Chalasani N. Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis: selected practical issues in their evaluation and management. Exit Disclaimer: You Are Leaving www.ihs.gov Hepatology. 2009 Jan;49(1):306-17.

Division of Diabetes Treatment and Prevention | Phone: (505) 248-4182 | Fax: (505) 248-4188 | diabetesprogram@ihs.gov