Management of nonalcoholic fatty liver disease in the Middle East

Abstract

The prevalence of nonalcoholic fatty liver disease (NAFLD) in the Middle East is increasing in parallel to an increase in the prevalence of associated risk factors such as obesity, metabolic syndrome, and type 2 diabetes mellitus. About 20% to 30% of the patients progress to develop nonalcoholic steatohepatitis (NASH), a histological subtype of NAFLD, with features of hepatocyte injury such as hepatocyte ballooning. NASH can progress to fibrosis, cirrhosis, and even hepatocellular carcinoma. NAFLD thus causes a substantial burden on healthcare systems and it is imperative that appropriate strategies are discussed at a regional level to facilitate effective management tailored to the needs of the region. To fulfil this unmet need, expert gastroenterologists, hepatologists, and endocrinologists from the region came together in three advisory board meetings that were conducted in Saudi Arabia, United Arab Emirates, and Kuwait, to discuss current local challenges in NAFLD screening and diagnosis, and the different available management options. The experts discussed the disease burden of NAFLD/NASH in the Middle East; screening, diagnosis, and referral patterns in NAFLD; and available treatment options for NAFLD and NASH. This paper summarizes the discussions and opinion of the expert panel on the management of NAFLD/NASH and also presents an extensive literature review on the topic.

Nonalcoholic steatohepatitis: global impact and clinical consequences

“…The Middle East and Northern Africa (MENA) may have the highest prevalence of NAFLD globally with a rate of 32%, and future projections demonstrate a worsening trend ( 24 ). In this context, worsening diabetes and obesity rates have been shown to be the main driver of this trend in MENA countries.…”

Real-world management of non-alcoholic steatohepatitis differs from clinical practice guideline recommendations and across regions

“…The aim of this analysis was to assess real-world clinical practice and compare this retrospectively to a standard of care represented by reference guidelines, regardless of whether clinicians were currently referring to guidelines or not. The welldocumented lack of availability or consensus on care pathways [19][20][21]39 made it difficult to conduct a universal assessment of the optimal standard of care for patients with NASH. Lack of availability coupled with extensive variation in national, and nationally endorsed, clinical practice guidelines for NAFLD 39 drove a decision to use the crossspecialty EASL-EASD-EASO guidelines, which we considered to be amongst the J o u r n a l P r e -p r o o f most comprehensive guidelines currently available and specifically relevant to the majority of territories sampled.…”

Clinical and economic burden of nonalcoholic steatohepatitis in Saudi Arabia, United Arab Emirates and Kuwait

“…This serious liver disease can no longer be perceived as a lifestyle disease. Regional clinical experts recently raised concerns regarding the national statistics of NASH and their impact and have called for urgent government and non-government organization action [24,28]. Importantly, proposed ME diagnostic and management roadmaps, respectful of cost and local expertise consideration, could contribute toward an action plan to identify and improve the SoC for people with NASH and AF-NASH [28].…”

“…There must be an immediate effort and commitment to address the increasing challenges and unmet needs facing the ME medical community. Actions need to be broad-ranging, comprehensive and collaborative with multidisciplinary input ensuring widespread adoption [24,28]. Areas for consideration to tackle issues of disease management and to raise its priority could include:…”

“…Pandemic levels of obesity [21] and T2DM [22] in the KSA, UAE and Kuwait (with average body mass indices of 28.5, 28.8 and 30.0, respectively) [21] together with their aging populations suggest that NAFLD/NASH-associated advanced liver disease and mortality will increase in these countries [23,24]. NAFLD prevalence in the ME is 32% [8], one of the highest worldwide, although there are limited data for individual countries.…”