Screen all adults with diabetes or prediabetes for liver disease, new standards say

The American Diabetes Association (ADA) recently released new standards of care recommendations for diagnosing and managing non-alcoholic fatty liver disease (NAFLD) in patients with diabetes. The new additions to the standards of care stress the importance of screening all adults with type 2 diabetes or prediabetes for NAFLD-related liver fibrosis, a guideline in keeping with other international liver or diabetes guidelines. “This recommendation is quite consistent across the different guidelines that are out there for endocrinologists, for primary care physicians and for gastro-hepatologists,” said Dr. Giada Sebastiani, professor of medicine at McGill University and clinical scientist at the McGill University Health Centre research institute. This consistency is important not only because it shows there’s consensus on the topic, but also because it emphasizes how NAFLD is a multi-system disease which needs a multi-disciplinary approach, Dr. Sebastiani told the Medical Post. Patients with diabetes are at highest risk for developing NAFLD, which includes non-alcoholic steatohepatitis, (NASH), the most common form of liver disease in people with diabetes. More than 15% of patients with diabetes have liver fibrosis due to NAFLD or NASH, which is four or five times higher than the general population. Canadian physicians managing patients with type 2 diabetes or prediabetes should screen for NAFLD-associated liver fibrosis every two years, Dr. Sebastiani said. The standards of care suggest that people with prediabetes should be included in the screening and treatment recommendations, “to avoid not only progression of the liver condition to NASH and cirrhosis, but also the insulin resistance to overt diabetes,” Dr. Sebastiani said. The tools to do an initial screening test are simple and accessible to most physicians. Risk of liver fibrosis can be calculated using fibrosis-4 index (or score), which uses a patient’s age, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and platelet count. The standards of care provide an example of fibrosis-4 index developed by Dr. Richard Sterling of Virginia Commonwealth University. A value lower than 1.3 is considered at low risk of liver fibrosis. “It is really important to rule out the patients who are not at risk for liver fibrosis,” Dr. Sebastiani said. Read: Powerful new obesity drug poised to upend weight loss care One drawback is that in some provinces, an AST test is only covered if ordered by a gastroenterologist, when it is primary care physicians who may be conducting the regular screening for NAFLD. The Canadian NASH network is trying to change this, Dr. Sebastiani said. If the fibrosis-4 index is not able to rule out the presence of fibrosis, physicians will need to do a second-line test, such as a liver stiffness measurement with transient elastography, or a blood biomarker such as the enhanced liver fibrosis (ELF) test. Unfortunately, some physicians may not have ready access to these second-line tests. The Canadian NASH Network is currently working “to expand the accessibility and to reduce the inequities across the different geographical regions in Canada,” Dr. Sebastiani said, who sits on the network’s steering committee. Read: New guidelines on type 2 diabetes remission Treating hyperglycemia The new standards also state that physicians can consider prescribing pioglitazone or glucagon-like peptide 1 (GLP-1) receptor agonists as the preferred agents for treating hyperglycemia in patients with diabetes and NASH and NAFLD. Using other glucose-lowering therapies may be continued as indicated, although they lack evidence of benefit in patients with NASH. While pioglitazone has been recommended in the liver guidelines for many years to treat NASH and NAFLD, GLP-1 receptor agonists are not included in many other guidelines because randomized clinical trials to test them as a treatment for NASH are ongoing, Dr. Sebastiani said. Weight loss improves liver fibrosis, and may even regress liver cirrhosis in some cases. “We are quite confident that because glucagon-like peptide 1 receptor agonists make you lose weight, this will also improve NASH and the overall metabolic health of the patient,” she said. Reducing cardiovascular risk factors The new standards of care recommend lifestyle changes that promote weight loss to patients with diabetes or prediabetes with NAFLD. This could include a nutrition plan and exercise program. Physicians should also ensure the patient’s cardiovascular risk factors are identified managed. This can include statins, except for people with decompensated cirrhosis. “The number one cause of mortality in patients with NAFLD is actually cardiovascular disease, it’s not liver disease,” Dr. Sebastiani said. Some may physicians have concern using statins in patients with liver fibrosis because they may increase liver transaminases, but Dr. Sebastiani said a mild elevation in liver transaminases will not negatively affect NASH or NAFLD. The American Diabetes Association standards of care are updated regularly as part of a living document. The standards are reviewed and updated by the American Diabetes Association’s professional practice committee, a multidisciplinary team of experts in the field of diabetes care. “Diabetes and liver disease are closely linked, and it is essential that healthcare professionals have the most current information to effectively detect and manage this disease,” Dr. Nuha El Sayed, chair of the American Diabetes Association professional practice committee and lead author of the standards of care guidelines said in a press release. The new standards of care are published in Diabetes Care. The section about NAFLD is included in section four, Comprehensive Medical Evaluation and Assessment of Comorbidities. The Canadian Diabetes Association, Canadian NASH Network and Canadian Association for the study of the liver are currently working on a clinical guidelines for NASH. Read: One in three diabetics found to have undetected heart disease

Screen all adults with diabetes or prediabetes for liver disease, new standards say

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