As a hospital pharmacist, you will see more nonalcoholic fatty liver disease (NAFLD). According to studies, up to 100 million Americans have this buildup of fat in the liver. It often goes hand in hand with obesity, dyslipidemia, insulin resistance, and diabetes.
About 20% of patients with NAFLD have nonalcoholic steatohepatitis (NASH), the more severe form with inflammation and sometimes fibrosis. It's set to be the top reason for liver transplants in the U.S. by 2020. But most NAFLD patients don't have symptoms and it's often discovered incidentally in the hospital. For example, a fatty liver may be seen during an MRI ordered to work up a separate medical issue. The tough part is that medications haven't been shown yet to decrease the risk of cirrhosis, liver transplant, or death.
Educate newly diagnosed NAFLD patients about the importance of weight loss with diet and exercise. Tell patients to aim for a 3% to 5% weight loss to reduce steatosis and at least 7% to reduce inflammation and possibly fibrosis.
Optimize medications for dyslipidemia, diabetes, hypertension, etc. For example, verify NAFLD patients are on a statin for dyslipidemia or to lower CV risk if needed. Reassure physicians and patients that statins can be safely used in NAFLD, even in NASH.
At discharge, consider pioglitazone (Actos) 30 to 45 mg daily, for NASH patients with or without diabetes. It seems to reduce steatosis, inflammation, and fibrosis. But continue to avoid pioglitazone in heart failure. NASH patients withOUT diabetes may also be taking vitamin E to possibly reduce steatosis and inflammation. Feel comfortable holding it in the hospital. But stay alert for bleeding if vitamin E is continued. FOR MORE INFORMATION, SEE OUR NOTE, "Overview of nonalcoholic fatty liver disease (NAFLD)" to help manage comorbidities.
REFERENCES
-
Chalasani N, Younossi Z, Lavine JE, Charlton M, Cusi K, Rinella M, Harrison SA, Brunt EM, Sanyal AJ. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2018 Jan;67(1):328-357. Available at: https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep.29367
Musso G, Cassader M, Paschetta E, Gambino R. Thiazolidinediones and Advanced Liver Fibrosis in Nonalcoholic Steatohepatitis: A Meta-analysis. JAMA Intern Med. 2017 May 1;177(5):633-640. Available at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2605526
Than NN, Newsome PN. A concise review of non-alcoholic fatty liver disease. Atherosclerosis. 2015 Mar;239(1):192-202. Available at: https://www.atherosclerosis-journal.com/article/S0021-9150(15)00030-1/fulltext