Bethesda, MD (October 1, 2021) – In collaboration with four professional associations, the American Gastroenterological Association (AGA) assembled a multidisciplinary taskforce of 15 experts to develop an action plan to develop a non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) Clinical Care Pathway providing practical guidance across multiple disciplines of care. The guidance ranges from screening and diagnosis to management of individuals with NAFLD and NASH, facilitating value-based, efficient, and safe care that is consistent with evidence-based guidelines.
NAFLD, a largely asymptomatic disease, is becoming increasingly common. Most patients are managed in primary care or endocrine clinics where screening and management is critical, as is the knowledge of which patients may benefit from secondary care to address hepatic manifestations, comorbid metabolic traits, and cardiovascular risk of the disease. This clinical care pathway is intended to be applicable in any setting where care for patients with NAFLD is provided, including primary care, endocrine, obesity medicine and gastroenterology practices.
NAFLD/NASH Screening Steps:
Step 1: Identifying patients with clinically significant hepatic fibrosis (fibrosis stage 2 or higher) is important for targeted efforts at preventing disease progression. These groups include patients with type 2 diabetes, patients with two or more metabolic risk factors, and those with incidental findings of hepatic steatosis or elevated aminotransferases.
Step 2: All at-risk patients identified in Step 1 should be screened for alcohol use and undergo liver function tests (or comprehensive metabolic panel, if done as part of routine care) and a complete blood count as part of the initial screening process.
Step 3: All individuals in the target risk groups should undergo non-invasive testing for clinically significant liver fibrosis using simple, non-proprietary fibrosis scores.
Step 4: Patients with discordant or indeterminate Liver Stiffness Measurement (LSM) results (8.0 to 12.0 kPa) in primary care and endocrine clinics should be referred to hepatology where they may need to undergo either a liver biopsy or magnetic resonance elastography (MRE) for further diagnostic evaluation.
Management of NAFLD/NASH
A multidisciplinary team, including a primary care provider, an endocrinologist for patients with diabetes, and a gastroenterologist/hepatologist, is needed to successfully manage the complexity of care posed by high-risk patients due to obesity, diabetes, CVD and NALFD with fibrosis. The primary goal of screening these patients is to implement early interventions to prevent the development of cirrhosis and liver-related and all-cause mortality. Providers must also try to help patients reverse the unfavorable metabolic profile as CVD is the primary cause of morbidity and mortality in patients with NAFLD/NASH before the development of cirrhosis. In all risk groups, appropriate physician-patient communication should guide shared decision-making.
- Patients at low-risk of advanced fibrosis should be managed using therapeutic lifestyle interventions, such as weight loss, as appropriate, nutritional strategies, stress management, regular physical exercise, and avoiding excess alcohol intake. Specific pharmacological treatment targeting liver steatosis is not necessary in this lower-risk population.
- Patients at high-risk advanced fibrosis should be managed by a multidisciplinary team closely coordinated by a hepatologist who can monitor for cirrhosis, hepatocellular carcinoma, and other cirrhosis-related complications. In these patients, we recommend aggressive lifestyle changes aimed at long-term weight loss, including a greater use of formal weight loss programs and potentially, surgery.
- Patients at indeterminate-risk of advanced fibrosis should be managed using a similar approach to high-risk patients, along with further work-up and efforts to confirm the stage of hepatic fibrosis. In some cases, proprietary plasma biomarker tests for fibrosis staging or additional imaging-based fibrosis measurement (i.e., MRE) studies may be used to guide patient care.
NAFLD is one of the most common causes of liver disease, affecting over 25% of the population globally, and more than 60% of patients with type 2 diabetes. While NASH – a more severe form of NAFLD – is less common, it is estimated to impact 4.9 million to 21 million Americans and more than 100 million individuals worldwide. NAFLD and NASH are thought of as “silent diseases,” meaning they have few or no symptoms. If they go untreated and worsen, patients may experience severe liver damage and require liver transplantation. Catching NAFLD and NASH early can help manage the disease and prevent complications. .
The multidisciplinary pathway development taskforce included medical professionals from the collaborating professional societies, the American Diabetes Association, American Osteopathic Association, Endocrine Society, and the Obesity Society. Panel members represented a range of clinical practices (private, academic university, Veterans Affairs) in the U.S., Europe, Australia and Asia.
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