Medical and Surgical Treatment Options for Nonalcoholic Steatohepatitis

Abstract

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of liver disease in the United States with a growing prevalence worldwide. Nonalcoholic steatohepatitis (NASH), progressive form of NAFLD can lead to the development of cirrhosis, hepatocellular carcinoma (HCC), and the need for liver transplantation. Treatment of NASH may decrease the risk of progressive disease. Treatment for NAFLD should center around weight loss and exercise. Pharmacotherapy with vitamin E and pioglitazone should be considered for those with NASH, especially those with fibrosis. Weight loss surgery is also an effective treatment for NASH in individuals with other indications for surgery. In this review we will discuss the currently available therapies for NASH including lifestyle, pharmacologic and surgical options.

Non-alcoholic fatty liver disease: an emerging driving force in chronic kidney disease

“…However, based on the complex, biological mechanisms discussed above, several pharmacological agents for the treatment of NAFLD are currently under investigation 118-120. Promising novel agents with anti-inflammatory, anti-fibrotic or insulin-sensitizing properties The therapeutic approach to patients with NAFLD is multifactorial 1,3,118,119 , as summarized in Figure 5. The first approach is the treatment of overweight and obesity (especially through appropriate changes in lifestyles or bariatric surgery for severe obesity), the optimization of glycemic control in patients with established diabetes and the treatment of all co-existing cardiometabolic risk factors, possibly with the use of therapies that may have potential beneficial liver effects.…”

“…The mainstay of management for NAFLD is lifestyle intervention, which includes a hypocaloric diet and regular physical exercise with a 5-10% weight reduction associated with improvement in hepatic steatosis and necroinflammation 1,3,118,119 . Resistance exercise may be more feasible than aerobic exercise for NAFLD patients with poor cardiorespiratory fitness or for those who cannot tolerate or participate in aerobic exercise.…”

“…Bariatric surgery, as a nonpharmaceutical effective treatment to decrease body weight in patients with severe obesity, markedly improves all histological lesions of NASH, including hepatic fibrosis 1,3,118,119 .…”

“…To date, pharmacotherapy for NAFLD should probably be reserved for patients with NASH (particularly for those with significant fibrosis or with the presence of metabolic risk factors), who are at the highest risk for disease progression 1,3,118,119 . However, no drug has currently been tested in phase III trials and is approved for NASH by regulatory agencies.…”

“…Randomized clinical trials have documented that pioglitazone treatment improves hepatic steatosis and necroinflammation, but not hepatic fibrosis, in patients with NASH and that its interruption may frequently determine the re-appearance of the liver damage 1,3,118,119 . Recently, a randomized, double-blind, placebo-controlled trial (including 101 patients with T2DM or pre-diabetes and biopsy-proven NASH randomly treated with pioglitazone, 45 mg/day, or placebo for 18 months, followed by an 18-month open-label phase with pioglitazone treatment) reported that 51% of patients treated with pioglitazone had resolution of NASH 122 .…”