Abstract

Background & AimsDespite availability of diagnostic and management reference guidelines outlining standard of care for patients with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH), national and regional guidelines are lacking, resulting in variations in patient management between regions. We retrospectively analyzed patient characteristics and management data from the Adelphi Real World NASH Disease Specific Programme™ for patients with NASH in the EU5, Canada, and the Middle East to identify gaps between real-world practice and that advocated by reference guidelines, irrespective of clinician awareness or consultation of guidelines.MethodsWe performed an analysis of physicians (hepatologists, gastroenterologists, diabetologists) and their patients diagnosed with NASH. Physicians completed patient record forms for the next 5 consulting patients, collecting information on patient care, including diagnosis and disease management.ResultsA total of 429 physicians provided data for 2,267 patients with NASH (EU5, n = 1,844; Canada, n = 130; Middle East, n = 293). Patient age, physician-defined fibrosis stage, comorbidities and symptoms, and diagnostic testing practices highlighted statistically significant differences across regions. Substantial disconnects between reference guidelines and real-world practice were observed. Use of liver function tests, non-invasive tests (e.g. ultrasound and transient elastography), and tests to exclude other conditions was suboptimal. Although lifestyle advice was widely provided, patients were less commonly referred to diet, exercise, and lifestyle specialists. Two-thirds of patients were receiving off-label treatment for NASH or associated underlying conditions with the aim of improving NASH, most commonly statins, metformin, and vitamin E.ConclusionReal-world NASH management approaches differ across regions and from proposed standard of care represented by reference multidisciplinary guidelines. Establishment and awareness of, and adherence to regional and national guidelines may improve identification and management of patients with NASH and potentially improve outcomes in this population.Lay summaryAlthough reference guidelines are available to guide the management of patients with NASH, these are not widely used and there is a lack of national guidelines. Our study shows how clinical practice in the EU, Canada, and Middle East differs from proposed standard of care, particularly relating to how patients are diagnosed and treated. Wider establishment of, awareness of, and reference to guidelines may improve how physicians identify and manage patients with NASH.

Highlights

  • Non-alcoholic steatohepatitis (NASH) is the progressive form of non-alcoholic fatty liver disease (NAFLD), an increasingly common disease associated with metabolic syndrome, which can lead to cirrhosis, hepatocellular carcinoma, and substantial morbidity

  • Data reveal substantial disconnects between recommendations in the crossspecialty EASL-European Association for the Study of Diabetes (EASD)-European Association for the Study of Obesity (EASO) guidelines,18 which might be considered a reasonable standard of care, and the diagnosis and management of patients with NAFLD/NASH in routine clinical practice

  • These guidelines are broadly aligned with the guidelines developed by the Asian Pacific Association for the Study of the Liver25 and, with the exception of statement #1, Association for the Study of Liver Diseases (AASLD) guidelines

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Summary

Introduction

Non-alcoholic steatohepatitis (NASH) is the progressive form of non-alcoholic fatty liver disease (NAFLD), an increasingly common disease associated with metabolic syndrome, which can lead to cirrhosis, hepatocellular carcinoma, and substantial morbidity. NAFLD/NASH carries a substantial socioeconomic burden which, coupled with rising prevalence, is an underrecognized but growing public health challenge. Careful management of patients with NASH is important, as reversal of NASH-associated fibrosis is possible but requires patients to make significant lifestyle changes targeting weight loss through dietary modification and increased physical activity. Sustaining changes to maintain weight loss is difficult. In their recent review, Povsic et al found no reports of sustained weight loss and impact on outcomes in people with NASH. Pharmacological intervention may be needed, the success of such approaches depends on the extent of liver damage and expected treatment outcomes. Despite availability of diagnostic and management reference guidelines outlining standard of care for patients with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH), national and regional guidelines are lacking, resulting in variations in patient management between regions. We retrospectively analyzed patient characteristics and management data from the Adelphi Real World NASH Disease Specific ProgrammeTM for patients with NASH in the EU5, Canada, and the Middle East to identify gaps between real-world practice and that advocated by reference guidelines, irrespective of clinician awareness or consultation of guidelines. Conclusion: Real-world NASH management approaches differ across regions and from proposed standard of care represented by reference multidisciplinary guidelines. Our study shows how clinical practice in the EU, Canada, and Middle East differs from proposed standard of care, relating to how patients are diagnosed and treated. Awareness of, and reference to guidelines may improve how physicians identify and manage patients with NASH.

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