Management of Nonalcoholic Fatty Liver Disease in Patients With Type 2 Diabetes: A Call to Action

Abstract

Traditionally a disease of hepatologists, nonalcoholic fatty liver disease (NAFLD) has recently become a major concern for a broad spectrum of health care providers. Endocrinologists and those caring for patients with type 2 diabetes mellitus (T2DM) are at center stage, as T2DM appears to worsen the course of NAFLD and the liver disease makes diabetes management more challenging. However, the nature of this relationship remains incompletely understood. Although the increasing prevalence of NAFLD is frequently attributed to the epidemic of obesity and is often oversimplified as the "hepatic manifestation of the metabolic syndrome," it is a much more complex disease process that may also be observed in nonobese individuals and in patients without clinical manifestations of the metabolic syndrome. It carries both metabolic and liver-specific complications that make its approach unique among medical conditions. Diabetes appears to promote the development of nonalcoholic steatohepatitis (NASH), the more severe form of the disease, and increases the risk of cirrhosis and hepatocellular carcinoma. Patients and physicians face many uncertainties, including fragmented information on the natural history of the disease, challenges in the diagnosis of NASH, and few pharmacological agents with proven efficacy. However, recent advances in diagnosis and treatment, combined with the risk of serious consequences from inaction, call for health care providers to be more proactive in the management of patients with T2DM and NASH.

A diabetologist’s perspective of non‐alcoholic steatohepatitis (NASH): Knowledge gaps and future directions

“…This mixed message about screening and intervention is understandable as the impact of early intervention on the natural history of steatohepatitis is incomplete. For instance, controlled trials of lifestyle interventions have all been shorter than 1‐year and few pharmacological interventions for NASH have gone beyond 2‐3 years . However, screening strategies for many diseases were originally not as evidence‐based as desired and vague guidelines risk confusing clinicians and resulting in inaction in primary care.…”

“…Of note, the model did not include the potentially higher rates of diabetes‐related micro‐ and macrovascular complications associated with NASH . These findings should alarm diabetologists and prompt them to become proactive by viewing NASH as a common and serious complication of T2DM that should be systematically screened …”

Glucagon like Peptide-1 Receptor Agonists for the Management of Obesity and Non-Alcoholic Fatty Liver Disease: A Novel Therapeutic Option

“…Vitamin E has been used with some success in non-diabetic patients 3. Newer agents tested including obeticholic acid and elafibranor have shown modest improvement on liver histology in NASH, but larger trials fully examining their safety and efficacy are ongoing 5. However, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have recently emerged as an attractive treatment option for patients with obesity and NASH.…”

NASH‐related cirrhosis: An occult liver disease burden

“…One of the main target audiences of these efforts should be the physicians that follow diabetic patients. As commented by Bertot et al, recent articles have shown a high prevalence of undiagnosed advanced fibrosis and cirrhosis in diabetic patients showing that NAFLD is an important health threat to diabetic individuals (14). In spite of that, recent guidelines from the American Diabetes Association include only a short paragraph on NAFLD without any recommendations on screening, diagnostic, or therapeutic actions (15).…”