Manage lifestyle early and aggressively to prevent, instead of treat, fatty liver
Click Here to Manage Email Alerts
Millions of dollars have been spent trying to find medications that could treat this complex disorder. The focus has been on drugs for more severe disease, as it leads to complications, and early stages have been somewhat ignored.
The hepatology field wants to target people who have advanced fibrosis, because those are the people at risk for more serious conditions, like cirrhosis. Today, metabolic dysfunction-associated steatohepatitis has become the No. 1 reason for liver transplant in the U.S., so of course, hepatologists are thinking about treating people at risk for transplantation.
In endocrinology, on the other hand, we need to treat the metabolic conditions that predispose to fatty liver. As an example, we’ve had a long history of ignoring prediabetes, and then finally the field recognized that prediabetes is important to take care of so we don’t have such a large number of people with diabetes. But we have yet to take control of the enormous burden of this disease on health care dollars.
‘Aggressively Manage Lifestyle Changes’
At least half of the people with MASH have diabetes, overweight and obesity, and that is where the glucagon-like peptide-1 analogs come in. Essentially, we’re not managing people with overweight or obesity or other metabolic conditions aggressively enough. Weight loss has to be the No. 1 goal, because as people lose weight, fatty liver tends to get better. If they have high triglycerides or hypertension or prediabetes, we must start aggressively managing those conditions plus the weight. Waiting to treat until people are in fibrotic stages is not sufficient.
The message is to aggressively manage lifestyle changes. This doesn’t mean you just tell your patients to eat healthy and lose weight — that’s not a good prescription. Weight has to be managed with nutritionists and dietitians and followed up to ensure progress. These patients should receive behavioral therapy and enrolled in focus groups so they don’t feel alone or helpless.
Few people can lose weight just with diet and exercise; they need medications. We should continue to use the GLP-1 analogs and glucose-dependent insulinotropic polypeptide combinations and triple agonists for metabolic control for people who need weight-loss therapy, and we need payers to approve these for coverage. If these medications aren’t successful, then surgery should be considered.
‘Prevention Better Than Cure’
The field of hepatology is naturally excited to have drugs to treat metabolic dysfunction-associated fatty liver disease/MASH. However, the currently FDA-approved medication is rather expensive and may not be covered by all payers. Primary care providers deal with patients with diabetes who can’t afford even basic oral medications like metformin, sulphonylureas and insulin let alone these newer drugs. Our lawmakers need to address health care affordability and equity issues so drugs are cheaper and made available to all.
Additionally, there have not been many studies done to look at the long-term effects of the GLP drugs, so they need to be used with caution. We should not dismiss other drugs, such as pioglitazone, that have been tried and tested even though they haven’t been FDA approved for MASH.
Now let’s talk about the lean patients with MAFLD/MASH. People, particularly from India or China, may not have generalized obesity but still have fatty liver. See the patient in front of you and treat appropriately based on their symptoms, presenting condition and laboratory workup, as well as their motivation and drug affordability.
The patient is a partner in their care, so be empathetic and listen, learn and then guide. Finally, we need to be screening at-risk people in primary care who do not yet have liver fibrosis but who could be at risk, particularly those with prediabetes, high triglycerides, hypertension, polycystic ovarian syndrome and both type 1 and type 2 diabetes. Consider what could occur if comorbidities are not closely managed. Prevention is better than cure.
- For more information:
- Rita Basu, MD, is the Endowed Professor of Diabetes Science in the division of endocrinology, diabetes and metabolism at the Heersink School of Medicine; senior scientist at the UAB Comprehensive Diabetes Research Center, Hugh Kaul Precision Medicine Institute and UAB Center for Exercise Medicine; and medical director of the Office of Human Research Protection. She can be reached at rbasu@uabmc.edu.
Collapse
Read more about
Click Here to Manage Email Alerts