Fatty liver disease: To treat or not

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Should nonalcoholic fatty liver disease (NAFLD) be treated? If so, what is the best treatment? What alternative functional medical treatments are effective?
—C.D. Ford Jr, MD, Sugar Land, Tex.

NAFLD has become the wastebasket term for chronic liver disease associated with the cluster of metabolic risk factors (obesity, diabetes, hyperlipidemia, etc.) that are quickly reaching epidemic proportions in the United States. Unfortunately, a gap still exists between the recognition of NAFLD as a potentially life threatening and debilitating obesity-related comorbidity and the establishment of effective therapy. The American Gastroenterological Association (AGA) published helpful guidelines in 2002 (Gastroenterology. 2002;123:1702-1704). Theoretically, treatment approaches can be divided into those aimed at the associated risk factors (diabetes control, lipid reduction, and weight loss) vs. those aimed at the disease itself (insulin sensitizers, antioxidants, or cytoprotective agents) (Curr Treat Options Gastroenterol. 2003;6:455-463). Few would argue that tight control of the associated metabolic risk factors, namely obesity and diabetes, would not have positive effects. Studies, in fact, have shown that even modest weight loss has significant benefits in reducing hepatic inflammation (Gut. 2004;53:413-419). Multiple pharmacologic agents have been explored individually or in combination, including vitamin E, ursodeoxycholic acid, pioglitazone, and metformin, but the trials to date have been small, uncontrolled, or inconclusive. Thus, as noted by the AGA, it is difficult to recommend a single pharmacologic agent with clinical confidence. For now, rational treatment should emphasize moderate weight loss, alcohol avoidance, and adoption of a regular exercise program. It should be emphasized that while these recommendations are general, they can have a significant positive impact on the patient's health in metabolic spheres beyond hepatic disease.
—Christopher Ruser, MD
(109-16)

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