IN HEALTHCARE LITERATURE

n Alcohol-related liver Disease Clinical Practice Guidelines

n French Association for the Study of the Liver. (2022, June 1). https://reference.medscape.com/viewarticle/974654

The French Association for the Study of the Liver recommends that general and specialty practitioners use the AUDIT-C questionnaire to assist in detecting excessive alcohol consumption. All patients with cirrhosis and/or hepatocellular carcinoma should be counseled to completely and permanently stop all alcohol consumption to limit the risk of excess mortality. Symptomatic alcohol withdrawal should be treated with benzodiazepines until symptoms disappear. Additionally, consider pharmacological treatment for promoting the maintenance of alcohol consumption targets (abstinence or reduced consumption) in dependent patients.

All patients with alcohol-related liver disease should undergo noninvasive assessment of liver fibrosis. To confirm the clinical suspicion of alcoholic hepatitis in patients who are potential candidates for specific treatment, a liver biopsy is recommended.

In the absence of liver biopsy, use the National Institute on Alcohol Abuse and Alcoholism classification to offer treatment only to patients with probable alcoholic hepatitis.

The following criteria is used to identify people with advanced alcoholrelated liver disease in the general population: aged ≥ 40–45 years with an AUDIT score predictive of hazardous consumption and/or consumption of ≥ 14 standard drinks/week.

n Nonalcoholic Fatty liver Disease Clinical Practice Guidelines

n American Association of Clinical Endocrinology (2022, June 1). https://reference.medscape.com/viewarticle/974587

The guidelines are designed to help clinicians screen and identify patients at risk for nonalcoholic fatty liver disease (NAFLD) in the primary care setting so they may receive appropriate treatment promptly.

 Screen all patients at high risk for NAFLD, including those with prediabetes, type 2 diabetes, obesity, and/or at least two cardiometabolic risk factors, or those with hepatic steatosis identified on imaging, and/or elevated plasma aminotransferase levels that persist for longer than 6 months.

 Evaluate those undergoing bariatric surgery for the presence and severity of nonalcoholic steatohepatitis (NASH); liver biopsy should be recommended for patients whose pre-surgical stratification suggests indeterminate or high risk for liver fibrosis.

 Use the fibrosis-4 (FIB-4) index, which is calculated using the patient’s age, AST level, platelet (PLT) count, and ALT level: FIB-4 score = age (years) x AST (U/L)/PLT (109/L) x ALT ½ (U/L). The FIB-4 index classifies patients as being at low, intermediate, or high risk for liver fibrosis. The FIB-4 is not recommended for pediatric patients because the age part of the equation is not accurate for them; liver enzyme tests are appropriate for pediatric patients at high risk resulting from clinical factors.

 Patients with low risk can be managed in primary care or endocrinology settings with an emphasis on management of obesity and prevention of cardiovascular disease. Studies about whether NAFLD is an independent risk factor for CVD and whether this risk increases as NAFLD progresses to more severe disease have shown mixed results, but lifestyle modifications (e.g., diet and exercise) and medications can help improve cardiometabolic health and reduce the increased cardiovascular risk linked with NAFLD.

 For those at intermediate risk, a second noninvasive test, such as a liver stiffness measurement by elastography or an enhanced liver fibrosis (ELF) test, is recommended. Referral to a liver specialist for additional testing, including possible biopsy, is advised for those with high risk or whose risk is still unclear after two non-invasive tests.

 Individuals with high risk on the FIB-4 require a hepatology referral. Those in intermediate- and high-risk groups require multidisciplinary management that includes a hepatologist, endocrinologist, and others for prevention of cardiovascular disease and development of cirrhosis.