How to manage non-alcoholic fatty liver disease?

Introduction In the broad scope of non-alcoholic fatty liver disease (NAFLD), non-alcoholic fatty liver disease (NASH) is a progressive disease that often develops into cirrhosis of the liver and increases the risk of hepatocellular carcinoma (HCC)
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The 2020 Japan NAFLD/NASH Management Guidelines is an update of the previous version of the guidelines.
The expert group proposed screening methods for liver fibrosis, HCC, and cardiovascular disease (CVD) in NAFLD patients.
This article mainly summarizes the core points of the guidelines.

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2020 JSGE/JSH Evidence-Based Clinical Practice Guidelines: NAFLD/NASH Management 1.
What is the most important histological factor for evaluating patient survival? The staging of liver fibrosis is closely related to overall and liver-related mortality
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It is of great significance to assess the grade of liver fibrosis in NAFLD patients
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(Level of Evidence: A; Strength of Recommendation: 1) Patient follow-up and screening for HCC and CVD 2.
How to follow up NAFLD/NASH patients? According to the level of liver fibrosis, it is important to follow up not only liver-related events, but also CVD and extrahepatic malignancies
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(Level of Evidence: A; Strength of Recommendation: 1) 3.
How should NAFLD/NASH patients be screened for HCC? HCC screening should be carried out based on liver fibrosis stages and risk factors for HCC
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However, considering cost and manpower factors, the best screening method remains to be determined
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(Level of Evidence: C; Strength of Recommendation: 2) 4.
Has the incidence of cardiovascular events increased in NAFLD/NASH patients? The incidence of cardiovascular events in NAFLD/NASH patients (especially the advanced liver fibrosis group) has increased
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For NAFLD patients with advanced fibrosis, examination and evaluation of their CVD prevalence should be considered
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(Level of Evidence: A; Strength of Recommendation: 1) NAFLD/NASH diet and exercise therapy 5.
What is the recommended diet for improving NAFLD/NASH? Weight loss through a low-calorie diet can improve liver function and liver fat changes in NAFLD patients
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In order to improve NAFLD/NASH, the guidelines recommend prioritizing optimization of energy intake and limiting lipid or carbohydrate intake according to the ratio of nutrient intake
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(Level of Evidence: C; Strength of Recommendation: 2) 6.
Is exercise beneficial to improve NAFLD/NASH? Although the effect of exercise on liver histology is not completely clear, it is recommended that patients use exercise therapy, because even using this therapy alone can also improve liver function and liver fat in patients with NAFLD
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(Level of evidence: B; Strength of recommendation: 2) NAFLD/NASH drug therapy 7.
Is vitamin E effective for NAFLD/NASH? Vitamin E can improve liver biology and histological parameters in patients with NASH and is recommended
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However, its long-term safety in patients with CVD, congestive heart failure or bladder cancer has not been fully evaluated
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8.
Are thiazolidinediones effective for NAFLD/NASH? Pioglitazone is recommended for the treatment of NASH patients with insulin resistance
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(Level of Evidence: A; Strength of Recommendation: 2) 9.
Are sodium-glucose cotransporter 2 (SGLT2) inhibitors effective against NAFLD/NASH? For NAFLD/NASH patients with type 2 diabetes, SGLT2 inhibitors can improve liver enzymes and liver histological performance, so SGLT2 inhibitors are recommended
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(Level of Evidence: C; Strength of Recommendation: 2) 10.
Incretin-related drugs [such as glucagon-like peptide-1 (GLP-1) analogs and/or dipeptidyl peptidase 4 (DPP-4) inhibition Agent] Is it effective for NAFLD/NASH? For NAFLD patients with type 2 diabetes, GLP-1 analogs can improve liver function and liver histology
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The efficacy of DPP-4 inhibitors is not stable
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(Level of Evidence: C; Strength of Recommendation: 2) 11.
Are drugs for dyslipidemia effective for NAFLD/NASH? HMG-CoA reductase inhibitors (statins) are recommended for the treatment of NAFLD/NASH patients with hypercholesterolemia
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However, the efficacy of ezetimibe is not stable
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(Level of Evidence: C; Strength of Recommendation: 2) 12.
Is angiotensin II receptor antagonist (ARB) or angiotensin II converting enzyme inhibitor (ACE) effective for hypertension patients with NAFLD/NASH? ARB or ACE is recommended for the treatment of NASH patients with hypertension
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(Level of Evidence: C; Strength of Recommendation: 2) 13.
Is the conventional dose of ursodeoxycholic acid (UDCA) effective for NAFLD/NASH? Conventional doses of UDCA are not recommended for the treatment of NAFLD/NASH
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14.
Are biguanides effective for NAFLD/NASH? Biguanides are not recommended for the treatment of NAFLD/NASH, because there is no evidence that they can improve liver enzymes and liver histology in patients with NAFLD/NASH
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(Level of Evidence: B; Strength of Recommendation: 2) References: Tokushige K, Ikejima K, Ono M, et al.
Evidence-based clinical practice guidelines for nonalcoholic fatty liver disease/nonalcoholic steatohepatitis 2020[J].
Hepatol Res.
2021 Sep 17.
doi: 10.
1111/hepr.
13688.
Contribution email: tougao@medlive.
cn