This article is more than 5 years old. Information may no longer be current.
Q&A: NASH Intervention Requires Mutual Learning Between Specialties
Click Here to Manage Email Alerts
Specialists from all medical fields have become more aware over the last few decades about how one disease can feed the development of others and that the need for co-management is crucial to optimize patient quality of life and life expectancy. As the incidence and prevalence of fatty liver disease grows in the U.S. and around the world, prevention of nonalcoholic steatohepatitis and commonly concurrent advanced fibrosis has become a concern outside of the field of hepatology.
Healio Gastroenterology and Liver Disease spoke with Kenneth Cusi, MD, FACP, FACE, professor of medicine and chief of the division of endocrinology, diabetes and metabolism at the University of Florida, about the co-management of patients who have corresponding risk factors for endocrine and hepatic disorders, especially in the face of rising obesity rates.
Q: Why is it important for endocrinologists to screen for fatty liver?
Cusi: It’s important for a couple of reasons. As endocrinologists, we have the population with the highest risk for NASH with fibrosis: patients with obesity who typically have long-standing type 2 diabetes. Typically, these patients are referred to us by their primary care physician after about 10 years of management because their condition has become more complicated.
Obesity and long-standing diabetes are the perfect storm for developing NASH. These two risk factors have also been commonly associated with a higher prevalence for fibrosis. Because we are seeing those with the highest risk for NASH, we can hopefully catch and diagnose the fatty liver before they have developed advanced fibrosis or cirrhosis, which is when they will need the liver specialist.
Q: How best can endocrinologists and hepatologists work together?
Cusi: While we do already, I think there has been a significant increase in awareness of hepatic complications in patients seen by endocrinologists. Now that the American Diabetes Association has highlighted the need to look for steatosis or elevated alanine aminotransferase in the association’s 2019 guideline, endocrinologists are more aware of the risk for NASH or NASH-related fibrosis.
Part of the problem is that endocrinologists are used to having precise tests — we measure glucose, HbA1c, hormones, and we can use these in a clinical context to make decisions. Unfortunately for fatty liver and NASH, imaging and noninvasive tests are not always as definitive as other tests, and endocrinologists do not typically have access to these options in our clinics — though that might change in the future.
If we can highlight the seriousness of NASH, and if we become more proactive, we can make a difference though early diagnosis, which will have a major impact on the natural history of the disease in endocrine practice.
Q: What should hepatologists know about patients coming from endocrinology?
Cusi: Hepatologists have led the way in educating endocrinology about the liver and extrahepatic complications. What hepatologists now have to do is identify these comorbidities in their patient with NASH early on, whether it be ordering a test for diabetes or even looking at cardiovascular risk factors. One problem I have heard from endocrinologists is that they send a patient to a liver specialist, but the liver specialist only rules out viral hepatitis or other rarer conditions without pursuing in-depth tests for fatty liver such as a biopsy. Moving forward, we must understand that a liver biopsy might be more important in these patients than previously thought. These teams are going to come together and truly have an impact in changing the quality of life for their patients.
We both, hepatologists and endocrinologists, need to expand the view of our patients and take them more as a whole, because both conditions feed each other. As much as any patient who develops NASH often has risk factors for diabetes, patients with diabetes are more prone to develop NASH. Finding that partner in the other specialty is a big factor in the success of managing these patients.
Q: How can specialists engage a patient in maintaining a healthy lifestyle change?
Cusi: We know that telling someone to lose weight or follow a specific diet doesn’t always work. Both endocrinologists and hepatologists need to look to structured programs that can follow patients on a regular basis. In our 20-minute visits, specialists can’t do that work.
There are two other problems we need to address. For one, there is a large knowledge gap, as most lifestyle intervention studies only have data for 6 months and none have gone beyond 12 months. We have a great need for better data on the long-term benefits of a structured lifestyle program. Secondly, our patients have poor coverage from insurance companies who have often dodged their social responsibility in offering proper weight-management programs. Both the liver and endocrine communities have to start demanding that health care insurance companies take responsibility of their patients.
Q: What’s the next step for these fields?
Cusi: We have a responsibility to offer treatment so that patients can avoid a very devasting disease like cirrhosis. It just takes a foundation of awareness and a few simple tests to get there. The other thing to keep in mind is that, while there are no FDA approved treatments for fatty liver or NASH just yet, we know that weight loss of even 7% is achievable by most patients and can completely halt disease activity. I believe endocrinologists can learn that that prevention of NASH is rather simple and that our patients deserve it.
- For more information:
- Kenneth Cusi, MD, FACP, FACE, can be reached at University of Florida College of Medicine, 1600 SW Archer Rd., Room H-2, Gainesville, FL 32610; email: kenneth.cusi@medicine.ufl.edu.
Disclosures: Cusi reports he has received researcher support from Cirius, Inventiva, Janssen, Novartis, Novo Nordisk and Zydus, and serves as a consultant for Bristol-Myers Squibb, Coherus, Deuterex, Eli Lilly, Janssen, Novo Nordisk, Pfizer, Poxel, Sanofi and Tobira Therapeutics.