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. 2016 Jan;9(1):4-12.
doi: 10.1177/1756283X15611581.

Practice patterns in NAFLD and NASH: real life differs from published guidelines

Mary E Rinella  1 , Zurabi Lominadze  2 , Rohit Loomba  3 , Michael Charlton  4 , Brent A Neuschwander-Tetri  5 , Stephen H Caldwell  6 , Kris Kowdley  7 , Stephen A Harrison  8
Affiliations

Practice patterns in NAFLD and NASH: real life differs from published guidelines

Mary E Rinella et al. Therap Adv Gastroenterol. 2016 Jan.

Abstract

Background: Management guidelines from the American Association for the Study of Liver Diseases/American College of Gastroenterology/American Gastroenterology Association published in 2012 for nonalcoholic fatty liver disease (NAFLD) and steatohepatitis (NASH) recommend weight loss, vitamin E and pioglitazone as effective therapies for the treatment of biopsy-confirmed NASH. However, little is known about how physicians in the US diagnose NASH or whether published guidelines are being followed.

Methods: We assessed current diagnostic and treatment patterns of the management of NAFLD and NASH among academic gastroenterologists and hepatologists in the US using a standardized survey developed to collect information regarding respondents' practice environments, diagnostic techniques, and medication usage in patients with NAFLD/NASH.

Results: We invited 482 gastroenterologists and hepatologists, predominantly from academic centers, of whom 163 completed the survey. Only 24% of providers routinely perform liver biopsy, predominantly among patients with elevated serum aminotransferases. Vitamin E is prescribed regularly by 70% while only 14% routinely prescribe pioglitazone. Despite recommendations to the contrary, ~25% prescribe pioglitazone or vitamin E without biopsy confirmation of NASH. Metformin is used as frequently as pioglitazone despite its proven lack of efficacy in NASH. Overall, 40-73% adhere to published guidelines, depending on the specific question. There was no significant difference seen in adherence to guidelines between gastroenterologists and hepatologists.

Conclusion: This survey suggests that clinical practice patterns among gastroenterologists and hepatologists for the management of NASH frequently diverge from published practice guidelines. Although liver biopsy remains the gold standard to diagnose NASH, less than 25% of respondents routinely require it to make the diagnosis of NASH. We conclude that NASH is underdiagnosed in gastroenterology and hepatology practices, highlighting the need to refine noninvasive diagnostic tools.

Keywords: diagnosis; liver biopsy; nonalcoholic fatty liver disease; nonalcoholic steatohepatitis; pioglitazone; practice guidelines; practice patterns; treatment.

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Conflict of interest statement

Conflict of interest statement: The authors declare no conflicts of interest in preparing this article.

Figures

Figure 1.
Figure 1.
Are elevated liver enzymes required for liver biopsy? GI, gastrointestinal.
Figure 2.
Figure 2.
Treatment recommendations: (a) all respondents; (b) gastroenterologists; and (c) hepatologists. NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis.
Figure 3.
Figure 3.
Annual number of patients with NAFLD or NASH referred for bariatric surgery. GI, gastrointestinal; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis.
See this image and copyright information in PMC

References

    1. Adams T., Gress R., Smith S., Halverson R., Simper S., Rosamond W., et al. (2007) Long-term mortality after gastric bypass surgery. N Engl J Med 357: 753–761. - PubMed
    1. Berry D., Wathen J., Newell M. (2009) Bayesian model averaging in meta-analysis: vitamin E supplementation and mortality. Clin Trials 6: 28–41. - PubMed
    1. Breunig I., Shaya F., McPherson M., Snitker S. (2014) Development of heart failure in medicaid patients with type 2 diabetes treated with pioglitazone, rosiglitazone, or metformin. J Manag Care Pharm 20: 895–903. - PMC - PubMed
    1. Caiazzo R., Lassailly G., Leteurtre E., Baud G., Verkindt H., Raverdy V., et al. (2014) Roux-en-Y gastric bypass versus adjustable gastric banding to reduce nonalcoholic fatty liver disease: a 5-year controlled longitudinal study. Ann Surg 260: 893–898; discussion 898–899. - PubMed
    1. Chalasani N., Younossi Z., Lavine J., Diehl A., Brunt E., Cusi K., et al. (2012) The diagnosis and management of non-alcoholic fatty liver disease: Practice Guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology 55: 2005–2023. - PubMed

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