Clinical Challenges: Approaches to Managing Steatotic Liver Disease

Derick Alison
Derick Alison
7 Min Read

Receiving a diagnosis of metabolic dysfunction-associated steatohepatitis (MASH; formerly nonalcoholic steatohepatitis, or NASH) may come as a shock to many people, especially when symptoms are vague or non-existent.

The progressive nature of this severe form of metabolic dysfunction-associated steatotic liver disease (MASLD) heightens the importance of timely diagnosis, which begins with targeted screening.

“Unfortunately, many patients with MASLD/MASH are diagnosed when they develop a complication such as cirrhosis or liver cancer. We need to do a better job at picking up MASLD earlier in the community setting before it progresses,” Hirsh Trivedi, MD, of Cedars-Sinai Medical Center in Los Angeles, told MedPage Today.

“There is increasing evidence that screening higher-risk populations, such as those with type 2 diabetes or metabolic syndrome, is beneficial,” he added. “The process is easily initiated by a primary care physician or endocrinologist using non-invasive serology testing.”

Overall, a multidisciplinary approach to patient care is important, Trivedi noted.

This includes pediatricians, said Susan Baker, MD, PhD, and Robert Baker, MD, PhD, of the University at Buffalo in New York. “Since the obesity epidemic, [MASLD] has become the most common cause of liver disease in children,” they told MedPage Today. “Pediatric [MASLD]/MASH is inherently different from adult disease, as the liver injury is beginning at a point with a lifetime to either progress or improve. There is not sufficient longitudinal data to say which is [more] likely.”

Children with a body mass index (BMI) over the 85th percentile and concomitant metabolic comorbidities, such as diabetes, insulin resistance, dyslipidemia, and central obesity, should be screened, beginning at about age 9, or younger in those with severe obesity and/or a family history of obesity, they explained. “Children with an ALT [alanine transaminase level] more than twice the upper limit of normal that persists for 3 months or more require further evaluation for chronic liver disease.”

In the absence of any approved medical treatments, lifestyle modification — with a focus on weight loss — is central to improving risk of progression of MASLD or MASH.

“Diet that achieves at least 5% weight loss can improve steatosis, and exercise can decrease fat in the liver, studies show,” said Jamile Wakim-Fleming, MD, director of the Center for Metabolic Steatosis of the Liver at the Cleveland Clinic. “Up to 10% weight loss may reduce inflammation and some degree of fibrosis.”

Trivedi noted that “research on the best diet is still evolving, but so far, the Mediterranean diet seems to be the most beneficial at reducing liver fat.” In addition, increasing data now show that exercise, even independent of weight loss, helps reduce progression, he added. “I advise patients to continue physical activity even if their weight loss has plateaued.”

The randomized TONIC study, which used follow-up liver biopsies, showed that diet and exercise reversed pediatric MASH in a quarter of patients. Unfortunately, three-quarters of the patients either worsened or did not change, Baker and Baker said.

Recommendations also include avoiding sugar-sweetened beverages, and limiting screen time to 2 hours daily, they added. “The resolve of the patient and family and the intensity of the lifestyle changes play big roles in the success of this initial intervention.”

According to Trivedi, achieving weight loss with lifestyle changes may be more difficult for those with more severe metabolic risk factors, such as uncontrolled type 2 diabetes. “However, when weight loss does occur, it often helps control diabetes-related insulin resistance and steatotic liver disease simultaneously; thus, it is still prudent to try to achieve significant weight loss,” he noted.

Along with the benefits of increased dietary omega-3 fats provided in the Mediterranean diet, one review suggested that one to two cups per day of caffeinated drip coffee may help decrease risk of both liver fibrosis and the incidence of hepatocellular carcinoma.

“Patients often ask me what the best ‘detox’ is for the liver,” Trivedi said. “I explain that we have no approved medication for that. Over-the-counter products are not regulated and may contain ingredients not listed on the label; thus, unnecessary supplements or remedies should be avoided. The best ‘detox’ for the liver is to avoid alcohol, exercise regularly, and eat a well-balanced nutritious diet.”

“I also advise all patients with chronic liver disease to be immunized against hepatitis A and B, and to keep routine vaccinations up-to-date,” he added.

In addition to reducing stigma associated with this liver disease, the American Association for the Study of Liver Diseases (AASLD) suggested the new patient-friendly terminology “should allow for the emergence of newly recognized disease subtypes to address the impact of disease heterogeneity, including the role of alcohol, on disease progression and response to therapy.”

Regarding the new subcategory of MetALD (i.e., MASLD in the setting of moderate alcohol consumption — 140 g and 210 g per week for women and men, respectively), Trivedi noted that in addition to destigmatizing liver disease, this new terminology “highlights the possible contribution of alcohol use to metabolic risk factors, a common scenario in about half of our patients. It also helps them understand the focus of disease management. When our advice aligns with the name of the condition, it makes communicating our recommendations much more clear.”

A coordinated multidisciplinary approach is important, said Trivedi. “Often, particularly in academic centers, having a multidisciplinary clinic or team following the patient helps emphasize the importance of optimizing metabolic parameters. For clinicians who aren’t at large academic centers, being aware of simple, non-invasive risk-stratification tools to inform when to refer patients is important. Having these discussions early in the community practice is paramount.”

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    Kate Kneisel is a freelance medical journalist based in Belleville, Ontario.

Disclosures

Trivedi disclosed relationships with Novo Nordisk, Sermo, and Guidepoint.

Wakim-Fleming, Robert Baker, and Susan Baker had no disclosures.

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