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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