Standard of Care in Diabetes 2024: ADA update emphasises screening people with diabetes for NAFLD and NASH

The updated Standards of Care in Diabetes-2024 is available online and is published as a supplement to the January 2024 issue of Diabetes Care.

This article will focus on screening people with diabetes for nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis at primary care and diabetes clinics.

Nonalcoholic fatty liver disease (NAFLD) includes a broad spectrum of diseases, ranging from macrovesicular hepatic steatosis (with or without mild inflammation) to nonalcoholic steatohepatitis (NASH) to cirrhosis. The updated recommendations on NAFLD screening and management are discussed below:

Screening

• Adults with type 2 diabetes or prediabetes, particularly those with obesity or cardiometabolic risk factors or established cardiovascular disease, should be screened/risk stratified for clinically significant liver fibrosis (defined as moderate fibrosis to cirrhosis) using a calculated fibrosis-4 index (FIB-4) (derived from age, ALT, AST, and platelets, even if they have normal liver enzymes.
• Adults with diabetes or prediabetes with persistently elevated plasma aminotransferase levels for >6 months and low FIB-4 should be evaluated for other causes of liver disease.
• Adults with type 2 diabetes or prediabetes with an indeterminate or high FIB-4 should have additional risk stratification by liver stiffness measurement with transient elastography or the blood biomarker-enhanced liver fibrosis (ELF).
• Adults with type 2 diabetes or prediabetes with indeterminate results or at high risk for significant liver fibrosis (i.e., by FIB-4, liver stiffness measurement, or ELF) should be referred to a gastroenterologist or hepatologist for further workup. Interprofessional care is recommended for long-term management.

Management

• Adults with type 2 diabetes or prediabetes, particularly overweight or obese, with nonalcoholic fatty liver disease (NAFLD), should be recommended lifestyle changes that promote weight loss, ideally within a structured nutrition plan and physical activity program for cardiometabolic benefits and histological improvement.
• For adults with type 2 diabetes, particularly overweight or obese, with NAFLD, consider using a glucagon-like peptide 1 (GLP-1) receptor agonist with demonstrated benefits in nonalcoholic steatohepatitis (NASH) as an adjunctive therapy to lifestyle interventions for weight loss.
• Pioglitazone or GLP-1 receptor agonists are the preferred agents for the treatment of hyperglycemia in adults with type 2 diabetes with biopsy-proven NASH or those at high risk with clinically significant liver fibrosis using noninvasive tests.
• In adults with type 2 diabetes and NAFLD, the use of glucose-lowering therapies other than pioglitazone or GLP-1 receptor agonists may be continued as clinically indicated, but these therapies lack evidence of benefit in NASH.
• Insulin therapy is the preferred agent for the treatment of hyperglycemia in adults with type 2 diabetes with decompensated cirrhosis.
• Adults with type 2 diabetes and NAFLD are at increased cardiovascular risk; therefore, comprehensive management of cardiovascular risk factors is recommended.
• Statin therapy is safe in adults with type 2 diabetes and compensated cirrhosis from NAFLD and should be initiated or continued for cardiovascular risk reduction as clinically indicated. Statin therapy should be used with caution and close monitoring in people with decompensated cirrhosis, given limited safety and efficacy data.
• Metabolic surgery should be considered in appropriate candidates as an option to treat NASH in adults with type 2 diabetes and to improve cardiovascular outcomes.
• Metabolic surgery should be used with caution in adults with type 2 diabetes with compensated cirrhosis from NAFLD and is not recommended in decompensated cirrhosis.

Reference:

American Diabetes Association Professional Practice Committee; 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes—2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S52–S76. https://doi.org/10.2337/dc24-S004