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Dr. Alkhouri:
This is CME on ReachMD, and I'm Dr. Naim Alkhouri. I'm the Chief Medical Officer and the Director of the Steatotic Liver Program at Arizona Liver Health. Joining me today is our physician assistant at Arizona Liver Health, Tessa Janovsky. We will start with the case of a 39-year-old, white man with elevated transaminase levels. past medical history includes ALT of 62 units per liter, AST of 56 units per liter, so mildly elevated, platelet count of 185,000, body mass index of 32 kg/m2, blood pressure in clinic was at 140/89, the triglycerides are at 172, and HDL cholesterol at 34, indicating the presence of metabolic syndrome. We did an alcohol screen, and that was within normal limits, with no excessive alcohol consumption. So the reason for the visit today is to follow up on the blood pressure, but also the lab results.
And with this, I want to hand it to you, Tessa. What would be the next step for you when you see a patient with these clinical characteristics in your clinic?
Dr. Janovsky:
Yeah, so we know he definitely has metabolic risk factors. He has obesity, hypertension, metabolic syndrome, and his liver enzymes are elevated. we want them to be in the 20s really, to be classified as normal in the hepatology clinic. So they're definitely two to three times the upper limit of normal. So, he definitely should be screened to see if he has any clinically significant fibrosis.
Dr. Alkhouri:
And how would you do this in your clinic, especially if you're in a primary care setting?
Dr. Janovsky:
Yeah, I mean, we have the ALT, we have the AST and the platelets and we know his age, so we can easily calculate the FIB-4 with any of the online resources available for calculation of the FIB-4, so that would be where I would start with this patient.
Dr. Alkhouri:
Excellent. So we calculated the FIB-4, and it comes back at 1.5. How would you interpret this?
Dr. Janovsky:
1.5 falls into that intermediate category. So he, you know, it's not negative, so he definitely could be at risk for clinically significant fibrosis, and it sounds like he needs to have an additional study. So, measuring his liver stiffness would be the next step in this case.
Dr. Alkhouri:
Excellent, and we did the VCTE, vibration-controlled transient elastography, and his liver stiffness came back at 8.7. So I think with the FIB-4 of 1.5 and the liver stiffness of 8.7, he's in that intermediate-risk zone. So what would you recommend for the management of this patient?
Dr. Janovsky:
For this patient, it's going to be really aggressive lifestyle intervention as well as, you know, managing his cardiovascular risk factors. So really talking to him and digging deep into his nutrition, talking to him about, you know, lowering his carbohydrate intake, lowering his simple sugars, increasing his activity, increasing his steps during the day, maybe talking about weight loss intervention. Is he a candidate for a GLP-1, or, you know, any sort of structured program? And then really looking at his cardiovascular risk factors and how can we really aggressively treat this patient, to put him in the to lower his risk of cardiovascular disease?
Dr. Alkhouri:
I totally agree. I think the only point I would make if this patient was a diabetic, also to make the right choice with the diabetes medications, and focus on medicines that may help fatty liver disease or steatotic liver disease, such as GLP-1 agonists, as you mentioned, but also consider pioglitazone.
Okay, so how about if we have the same patient, same clinical characteristics, but let's say the lab values are different, and now we calculate the FIB-4 forward comes back at 3.1 and the stiffness is at 12.8 kilopascal. What's your assessment of a patient with these values?
Dr. Janovsky:
So these values definitely put this patient at high risk for clinically significant fibrosis. They should be sent straight to a hepatology clinic, somewhere that has a multidisciplinary approach to treatment and really, you know, seeing if he’d be a candidate for any pharmaceutical therapy, maybe some clinical trials, but that score of liver stiffness measurement of 12.8 is definitely putting him at risk for clinically significant fibrosis, and we need to intervene as soon as possible.
Dr. Alkhouri:
I completely agree. So I think the message is determine the stage of the disease, and when you have, you know, patients with high risk of having advanced disease, send to a hepatologist, and we have some good treatment options. Thank you so much.
Dr. Janovsky:
Thank you.
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