Hepatologists, gastroenterologists lead NASH diagnosis yet ‘underdiagnosis’ persists
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Gastroenterologists and hepatologists were leaders in nonalcoholic steatohepatitis diagnosis and viewed as primary coordinators of care, but the condition is still underdiagnosed and undertreated overall, noted data in BMC Gastroenterology.
“The prevalence of NASH is increasing, but more concerning is the disproportionate increase in those with advanced fibrosis, hepatocellular carcinoma and hepatic decompensation predicted by modeling studies,” Mary E. Rinella, MD, professor of medicine and director of the metabolic and fatty liver disease program at UChicago Medicine, and colleagues wrote. “In the United States, NASH is currently the leading indication for liver transplant in women and those >65 years of age and is predicted to become the overall leading indication for liver transplant.
“NASH is underdiagnosed as patients are often asymptomatic or present with non-specific symptoms,” the researchers wrote. “The requirement for liver biopsy to confirm diagnosis could be contributing to the underdiagnosis of NASH; liver biopsies are potentially dangerous, resource-intensive and have limited scalability. The field is looking to non-invasive tests to identify those at most risk, who can then be targeted for therapy or more confidently exclude those who do not need specialty care.”
To evaluate the medical journeys of patients with NASH and pinpoint areas for improvement in their care, Rinella and colleagues conducted a population-based, cross-sectional online survey from Nov. 10, 2020, to Jan. 1, 2021, which was completed by 226 health care professionals who treat patients with NASH, 75 of whom were hepatologists and gastroenterologists, and 152 patients with the disease. The researchers focused on responses from patients and the 75 hepatologists and gastroenterologists.
According to patient survey results, tests that led to a formal NASH diagnosis were ordered by hepatologists (40%) and gastroenterologists (27%), and most patients received an official diagnosis of NASH from a hepatologist (37%) or a gastroenterologist (26%).
In addition, 52% of patients and 68% of hepatologists and gastroenterologists agreed that hepatologists and gastroenterologists are primary coordinators of NASH care.
The majority of those specialists (85%) reported being aware of AASLD clinical practice guidelines for NASH, with 86% saying they considered these guidelines in diagnosis.
A greater percentage of hepatologists and gastroenterologists used FibroScan (Echosens), or transient elastrography, to confirm NASH diagnosis compared with other health care professionals (88% vs. 68%). A reported 89% of hepatologists and gastroenterologists also distinguished between NASH with or without fibrosis, whereas only 60% of primary care physicians and 67% of endocrinologists did the same.
Patients with severe fibrosis have greater morbidity and mortality risks, according to researchers, although survey results showed 44% of patients received NASH diagnoses without qualifiers such as fibrosis severity.
The management methods for NASH most frequently recommended by hepatologists and gastroenterologists included exercise (86%), diet (70%) and supplements (58%), with few prescribing medications for comorbidities. The researchers suggested inexperience with anti-obesity medications may prevent these specialists from “utilizing all available resources to treat NASH.”
Hepatologists and gastroenterologists reported the primary reasons patients discontinue NASH treatment are difficulty (67%) and unwillingness (64%) to adhere to lifestyle changes.
“NASH is a growing problem and will likely be the primary cause of liver transplant in the near future,” the researchers wrote. “To meet the needs of this growing patient population and curb the increase, awareness must be raised, diagnosis rates increased and treatments improved.”
According to Rinella and colleagues, hepatologists and gastroenterologists can utilize their roles as primary NASH care coordinators to improve diagnosis and treatment practices.
“Hepatologists and gastroenterologists should embrace a multidisciplinary approach to NASH treatment, and national guidance should be updated to clearly define roles and responsibilities of various clinicians,” they concluded.
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Christos S Mantzoros, MD, DSc, PhD
The paper by Rinella and colleagues reports several interesting findings on the basis of a cross-sectional survey, and responses by patients and gastroenterologists are analyzed and presented, including:
1. “Most patients reported receiving their diagnosis of NASH from a hepatologist (37%) or gastroenterologist (26%).” This apparently reflects current status in the field but is apparently not sufficient in the long-term, given that approximately 25% of the general population has excessive fat in their liver and 20% of those individuals may have NASH.
In the future, we would like to see primary care doctors or metabolism experts be able and willing to make the diagnosis in their office, since we now understand that NAFLD is actually fatty liver disease mainly caused by obesity, sarcopenia, dysmetabolic profile (including dietary indiscretion and lack of exercise) and, in a minority of cases, lipodystrophy or genetic factors.
2. “Hepatologists/gastroenterologists were more likely than other health care professionals to use FibroScan (transient elastography) to diagnose NASH and were more likely to distinguish between NASH with or without fibrosis.” FibroScan is not difficult to use nor is it expensive, and thus more primary care or metabolism practices may be able to use it in the future, in addition to familiarizing themselves and using indexes such as FIB-4, APRI and ELF, which are based on simple blood tests.
3. “Hepatologists/gastroenterologists (68%) and patients (52%) agree that hepatologists/gastroenterologists are the primary coordinators of NASH care.” We believe that in the future, interdisciplinary teams composed of metabolism experts and gastroenterologists will be leading the field in collaboration with the primary care physicians who are more familiar with lifestyle modification and use of weight loss medications.
4. “The majority of hepatologists/gastroenterologists (85%) are aware of American Association for the Study of Liver Diseases (AASLD) clinical practice guidance, and 86% of those aware consider them when diagnosing patients with NASH. Hepatologists/gastroenterologists most frequently recommended exercise (86%), diet (70%) and supplements (58%) for ongoing management of NASH. Pharmaceutical medications for comorbidities were prescribed by a minority of hepatologists/gastroenterologists for their patients with NASH.”
These therapies will probably have to be applied much more effectively in the primary care setting in the future, and thus we should be expecting that patients with NAFLD/NASH will have more intensive lifestyle modification and use of weight-loss or similar effective medications in the future. This is particularly important given that NAFLD/NASH is so closely related not only to genetics, lifestyle and dysmetabolism — including diabetes, hypertension, hyperlipidemia, etc. — but also to atherosclerotic cardiovascular disease. Thus, a holistic approach as part of a multidisciplinary team effort would probably best serve our patients in the future. Moreover, we have recently proposed that based on recent advances in our understanding of the disease we change the name from NAFLD to FLD, as an accurate umbrella diagnosis, and we consider several subclassifications of the disease for more precise and personalized diagnosis and treatment.
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Jamile’ Wakim-Fleming, MD, FACG, FAASLD
This study by Rinella and colleagues shows that among health care providers, NASH is mostly recognized by gastroenterologists and hepatologists, but remains overall underdiagnosed and undertreated, and that requires improvement.
The authors recommend coordination of care among specialists, a multidisciplinary approach and more frequent follow-ups — we strongly support this recommendation. In fact, we developed the Fatty Liver Disease Medical Home at Cleveland Clinic to manage patients with NASH who also have obesity and cardiometabolic disorders.
Historically, NASH was first quoted by Ludwig et al in 1980, non-invasive tests first became available in 2003, and GLP-1 RA (liraglutide) were first approved to treat obesity in 2014. Since that time, and due to their benefits in NASH, multiple trials involving GLP-1 RA and other potential therapies are in their phase 3 trial for the treatment of NASH-specific. While research is ongoing and we hope for an FDA-approved medical treatment of NASH down the road, a multidisciplinary approach to treat patients with NASH is strongly advised.
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The work by Rinella and colleagues clearly tells the story about how hard it is for clinicians to modify their practice behavior. While 85% of hepatologists/gastroenterologists were aware of the AASLD guidelines and more often made the diagnosis, only 41% prescribed pioglitazone, a diabetes medication shown in five randomized controlled trials to be effective to treat steatohepatitis and recommended in the AASLD guidelines.
In addition, only 26% prescribed anti-obesity medications/GLP-1 RAs. Numbers were worse for primary care physicians and endocrinologists. We hope the recently released 2022 American Association of Clinical Endocrinology guidelines cosponsored by AASLD — especially targeting PCPs and endocrinologists — will shake treatment inertia in the future.
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