Clinical Care Pathway for the Risk Stratification and Management of Patients With Non-alcoholic Fatty Liver Disease

Abstract

We read with interest the article, “Clinical care pathway for the risk stratification and management of patients with nonalcoholic fatty liver disease” in the November issue of Gastroenterology.1Kanwal F. et al.Gastroenterology. 2021; 161: 1657-1669Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar We agree with many of the points the authors made, including the steps for screening for non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH), when to refer to Hepatology, and management of NAFLD and NASH with weight loss. We also agree that the degree of weight loss, specifically 10% or more total body weight loss (TBWL), may be important for resolution or improvement in all histologic features of NASH, including fibrosis. However, we were disappointed that the authors did not include endoscopic bariatric and metabolic therapies (EBMTs) for patients with NAFLD/NASH who have obesity or over-weight. In clinical practice, these therapies achieve more than 10% TBWL in most patients, which is higher than weight loss achieved by most of the anti-obesity medications in clinical practice. While bariatric surgery has the highest weight loss of any anti-obesity intervention and achieves >10% TBWL in most patients, only patients with body mass index ≥40 kg/m2 or ≥35 kg/m2 with at least 1 comorbidity are eligible. Of those who are eligible, fewer than 2% choose to undergo surgery, leaving many patients with obesity and NASH who do not qualify for or do not want surgery untreated or insufficiently treated. Currently, there are 3 types of EBMTs that are commercially available in the U.S. These include aspiration therapy, endoscopic sleeve gastroplasty, and intragastric balloon, all of which have been shown in meta-analyses to be associated with >10% TBWL with data supporting improvement in NAFLD/NASH surrogates. From a weight loss standpoint, aspiration therapy and endoscopic sleeve gastroplasty have been shown to be associated with long-term efficacy of 15.9% and 19% TBWL at 4 and 5 years, respectively, with the American Society for Gastrointestinal Endoscopy (ASGE) endorsing the use of aspiration therapy and data from a randomized controlled trial on endoscopic sleeve gastroplasty being published.2Nystrom M. et al.Obes Surg. 2018; 28: 1860-1868Crossref PubMed Scopus (33) Google Scholar, 3Sharaiha R.Z. et al.Clin Gastroenterol Hepatol. 2021; 19: 1051-1057.e2Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 4Jirapinyo P. et al.Gastrointest Endosc. 2021; 93: 334-342.e1Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Intragastric balloons are associated with 11.3% TBWL at 12 months (6 months after balloon removal).5Abu Dayyeh B.K. et al.Gastrointest Endosc. 2015; 82 (425-38.e5)Google Scholar Although intragastric balloons have been criticized for their short-term use, many patients who pursue treatment with intragastric balloon choose it because they are removable, most patients maintain the majority of their weight loss after removal for 6–12 months, and it is a repeatable therapy which has been recommended for use by both the American Gastroenterological Association and ASGE. In addition, there are data supporting its use in combination with pharmacotherapy to sustain the lost weight. In addition to achieving 10% or more TBWL, all of the currently available EBMTs have been shown to reduce liver enzymes, hepatic steatosis, and liver fibrosis,6Jirapinyo P. et al.Clin Gastroenterol Hepatol. 2021; 20: 511-524.e1Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar,7Bazerbachi F. et al.Clin Gastroenterol Hepatol. 2021; 19: 146-154.e4Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar which is likely related to the degree of weight loss achieved with these therapies, and further supports their use in the clinical care pathway for patients with NAFLD/NASH. Although we agree with the use of anti-obesity medications and we use them in our practices, anti-obesity medications are used short-term in the majority of patients. In a recent analysis of more than 44,000 patients prescribed anti-obesity medications in a large claims database, only 15.9% to 41.8% of patients continued to fill their prescriptions at 6 months and 7.2% to 28.2% of patients continued to fill their prescriptions at 12 months.8Ganguly R. et al.Diabetes Res Clin Pract. 2018; : 348-356Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Because weight regain starts to occur when an anti-obesity medication is stopped, this short-term use may limit the usefulness of these medications to treat NAFLD/NASH. Given these data and the usefulness of EBMTs in the treatment of patients with obesity and NAFLD/NASH, we strongly urge the authors to make a correction to the clinical care pathway to include bariatric endoscopists in the multidisciplinary team for management of patients with NAFLD/NASH, especially those with clinically significant hepatic fibrosis, and the use of EBMTs in patients with NAFLD/NASH and obesity or over-weight. We also urge the authors to use people-first language when describing patients with over-weight or obesity. Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver DiseaseGastroenterologyVol. 161Issue 5PreviewFind AGA's NASH Clinical Care Pathway App for iOS and Android mobile devices at nash.gastro.org. Scan this QR code to be taken directly to the website.Nonalcoholic fatty liver disease (NAFLD) is becoming increasingly common, currently affecting approximately 37% of US adults. NAFLD is most often managed in primary care or endocrine clinics, where clinicians must determine which patients might benefit from secondary care to address hepatic manifestations, comorbid metabolic traits, and cardiovascular risks of the disease. Full-Text PDF ReplyGastroenterologyVol. 162Issue 7PreviewWe appreciate the support received by Sullivan et al to our clinical care pathway for patients with non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH)1,2 as well as for highlighting the potential for endoscopic bariatric and metabolic therapies (EBMTs) to assist patients who have obesity or are overweight. We agree with the challenges of inducing and maintaining weight loss, with poor long-term adherence to weight management medications, and that EBMT may hold promise within this context. Full-Text PDF