Let’s Rewind: Recognizing NAFLD/NASH in the Primary Care Clinic

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Welcome to CME on ReachMD. This activity, titled “Let’s Rewind: Recognizing NAFLD/NASH in the Primary Care Clinic” is provided by Prova Education.

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Dr. Flamm:   
At least 30% of people in the United States have nonalcoholic fatty liver disease, or NAFLD, and as many as 4.5 million people are in advanced stages of disease without even knowing it. Can you recognize the signs in your clinic?  

This is CME on ReachMD, and I'm Dr. Steven Flamm. 

Dr. Bernstein:   
And I'm Dr. David Bernstein. 

Dr. Flamm:   
Today we're meeting Becca, a 35-year-old woman who is in the office due to hypertension and elevated liver enzymes. Her physical exam shows she has a BMI of 31.1 kg/m2, and her blood pressure is 158/90. She's on both metformin and lisinopril.  

Let's watch this patient-clinician interaction to see how easy it is to miss common risk factors for NAFLD and nonalcoholic steatohepatitis, or NASH, during an everyday encounter.  

Doctor:
Hi, Rebecca, it’s really nice to see you. How are you doing today? 

Patient:
Good, thank you. How are you? 

Doctor:
I’m doing well, thank you for asking. So the reason I’ve asked you to come into my office today is I want to review some lab results with you and see what we can do to get you back on track.  

So as you know, I’ve had some concerns for some time regarding your uncontrolled hypertension, your elevated liver enzymes, and even your recent weight gain. Your blood pressure at your last visit was 158/90 and your BMI was 31.1. Since you’ve been diagnosed with diabetes, we really need to start taking some steps to get your overall health under control.  

Patient:
I’m also concerned with my recent weight gain. I haven’t changed anything with my diet or exercising, but I’m continuing to gain weight. I’m tired all the time and I’m starting to notice how bloated and swollen I am in pictures. What do you suggest I focus on first to improve my overall health?  

Doctor:
Well, I’m going to recommend that we adjust the doses of your metformin and your lisinopril. I’m also going to give you some handouts that have some great information about healthy eating and exercise regimens. I think that’ll help jumpstart your progress.  

Patient:
Thank you so much. I’ll definitely read through those and make some changes. 

Doctor:
That’s great to hear. I’m glad that you’re on board. I’m also going to ask that you come back and see me in 6 months for a follow-up just so I can see how you’re doing. And also, don’t hesitate to call the office or make an appointment sooner if you feel like your health continues to decline. 

Dr. Flamm:   
After seeing this interaction, there are a few issues we need to address. To start off, Dr. Bernstein, what is fatty liver, and why should primary care physicians be thinking about this disease? 

Dr. Bernstein:   
So thank you, Dr. Flamm, for having me, first of all. So what is fatty liver? Fatty liver is actually what it sounds like: it's fat that is in the liver. And it's a spectrum of disease. So you can have just fat, you can have fat and inflammation, as we've termed NASH, we can have fat and scarring or fibrosis, and we can have cirrhosis. Why it's important is that it's incredibly common. About a third of the population has fatty liver, so about 110 million people, most of whom do not know that they have this, have no symptoms, and we don't recognize that they have a problem until some event occurs.  

So it's really important for primary care doctors to recognize who may have fatty liver and then determine how one can intervene to prevent the disease from progressing. Because there are ways that we have currently that we can intervene with patients if found early and prevent disease progression.  

Steve, what's the importance of identifying NAFLD or NASH? And what do we do next?  

Dr. Flamm:  
Well, you've highlighted one of the major issues with fatty liver, David: how common it is. This is not one of those diseases that practitioners will not encounter. They will see it in their practice every single day. Not only will they see it every day, but it's often silent, it's very tricky to diagnose, and it's frequently missed. Patients who have fatty liver, David, typically have any 1 of 3 things. They have hyperlipidemia, usually hypertriglyceridemia or low HDL levels. They have type 2 diabetes mellitusor obese or some combination of the 3. In fact, many patients have the all-too-common metabolic syndrome, where they have features of other medical issues as well. So these are problems that primary care providers see every day. And yet, patients don't have symptoms from this disease most of the time. Their liver enzymes may be elevated, which should call attention for a provider to actually look into fatty liver, but many even have normal liver enzymes.  

So why is it important? Because a fraction of these patients, David, silently are developing progressive liver disease, and in the end, they will develop cirrhosis, even though many of them don't even drink alcohol. So providers have to have awareness, have vigilance for this. When they see patients with these types of underlying problems, they need to think about fatty liver, and they need to try to diagnose it.  

And how you can diagnose it easiest in practice is with an ultrasound. So if a provider has an inclination that a patient might have fatty liver, they should do an ultrasound on the patient to see if there's evidence of steatosis. Because if there is, these are patients that need additional testing. Now, not all of them, David, need to be referred to a specialist, and we're going to discuss this shortly — 

Dr. Bernstein: 
Yes, we are. 

Dr. Flamm: 
—but many do, and it's incumbent upon the primary care provider to identify this at a stage where it's early enough that we can intervene and prevent the development of advanced liver disease if possible.   

Now that we have the basics, let's rewind the tape and see how this clinician improved his interaction with Becca.   

Doctor:
Hi, Rebecca, it’s really nice to see you. How are you doing today? 

Patient:
Good, thank you. How are you? 

Doctor:
I’m doing well, thank you for asking. So the reason I’ve asked you to come into my office today is I want to review some lab results with you and see what we can do to get you back on track.  

So as you know, I’ve had some concerns for some time regarding your uncontrolled hypertension, your elevated liver enzymes, and even your recent weight gain. Your blood pressure at your last visit was 158/90 and your BMI was 31.1. Since you’ve been diagnosed with diabetes, we really need to start taking some steps to get your overall health under control.  

Patient:
I’m also concerned with my recent weight gain; I haven’t changed anything with my diet or exercising, but I’m continuing to gain weight. I’m tired all the time and I’m starting to notice how bloated and swollen I am in pictures. What do you suggest I focus on first to improve my overall health?  

Doctor:
So I have some ideas of what might actually be going on. I got your ultrasound results back and it does show some evidence of steatosis. That’s more commonly known as fatty liver. If you don’t mind, I’d like to ask about your alcohol use. On average, how many drinks do you have per week? 

Patient: Well, that’s easy. I never drink. I don’t like the way it tastes and, even more, I’ve always hated the way it made me feel.  

Doctor:
Well, that’s good. And knowing that, and with your lab results, this leads me to believe that you might be at risk for something we call nonalcoholic fatty liver disease, or NAFLD, or nonalcoholic steatohepatitis, or NASH.  

I’m going to use the FIB-4 calculator. I actually ran your numbers earlier. Let me just pull that up on your chart. The FIB-4 calculator, it’s an index that we use to assess for the risk of liver fibrosis. And what we do is that we input certain data such as your age, platelet count, as well as your liver enzyme levels to determine your score. So your FIB-4 score came back as 3.23, and unfortunately, anything over 2.67 is considered as high risk for advanced fibrosis.  

Patient:
What does that mean? 

Doctor:
What that means is that there’s probably already fibrosis or damage to your liver, which, if we don’t address, could lead to liver failure. However, studies show that it can be reversed. I’m going to recommend that we start you with some lifestyle modifications, but what we really need to do here is to refer you to a hepatologist. That’s a liver specialist. They’ll be able to review your lab results and your history and be able to make some recommendations for some more permanent solutions. 

Dr. Flamm:   
For those just tuning in, you're listening to CME on ReachMD. I'm Dr. Steven Flamm, and here with me today is Dr. David Bernstein. Today, we're discussing the importance of being able to recognize NAFLD and NASH in everyday practice. 

This interaction ended with the doctor calculating the FIB-4 score and referring Becca to a specialist. Dr. Bernstein, why are both steps important? 

Dr. Bernstein:   
Steve, that's a great question. We've already laid out that fatty liver disease is common, and it's in about one-third of people in the United States, which means, for example, if a practitioner was seeing 30 patients in a given day, as many as 10 are going to have fatty liver, most of whom are unrecognized. If you really would then say, “How do I assess those 10 patients and make a determination who then needs to be sent on for further care?” Because currently, the specialists who care for these patients, mostly hepatologists and gastroenterologists, don't have the bandwidth to see everybody. The FIB-4 test then, a simple, noninvasive, easy-to-calculate score which utilizes 4 different types of parameters: the 2 liver transaminases, ALT and AST, the platelet count, and age, and that can be put into a computer and a number quickly generated. If that number is low, then the patient likely does not have significant scarring, and that's a patient that can be followed by the primary care doctor and does not need referral. If the score is high, that patient almost definitely has significant fibrosis or even cirrhosis, and that patient should be referred right away.  

There's a gray zone, an intermediate zone. That's also a zone or a number that should require some type of referral for further testing that the primary care doctor doesn't do but that the specialists will do.  

And I think that as primary care doctors begin to look for these patients and get comfortable with using the FIB-4, it's an excellent screening test to determine who they can keep and care and give a plan of diet, exercise, and who needs to be sent for further testing because they may have advanced disease. And as you know, many of their patients, unbeknownst to them or the patient, are going to have significant disease. 

Dr. Flamm:   
And it's very important, as you point out, David, that we need to find it as early as possible. And because it's silent, that's the importance of the healthcare practitioner having awareness of this problem. 

Dr. Bernstein:   
Don't look now, Dr. Flamm, but Becca has been referred to you. What happens now that she's sitting in your office and wants to learn more about her condition? And she's anxious. 

Dr. Flamm:   
Yeah, well, people, when they're referred to me, David, are frequently anxious. But we see patients like Becca all the time. And when they have a high fibrosis score on that noninvasive fibrosis test, like FIB-4, or an intermediate score, those are ones that we're more concerned about because those are the patients that really require intervention. And by the way, what intervention do you use at present? Lifestyle modifications. They're very important. I mentioned earlier what types of problems are risk factors for the development of fatty liver, and all of those need to be dealt with. If patients have hyperlipidemia, that needs to be treated. And in fact, I want to point out that statins are not contraindicated, David, in patients with this type of a liver problem. Second, if they have type 2 diabetes mellitus, that has to be aggressively treated. And thirdly, if they are overweight, which many of these patients are, aggressive attempts at weight loss are prudent. In fact, some of these patients benefit from going to a lifestyle clinic if there's one in the local community where they live.  

And I want to further point out that there are medications that are in late-stage development that we will have for use in patients with fatty liver. And they will be, when they're used, dependent upon the stage of liver disease, as determined by tests like the FIB-4.  

So it's very important for us to identify this disease, David, to stage it, determine who needs to be sent to a specialist, and then apply interventions for them which might help them.  

And I want to point out one other thing. Even when patients are asymptomatic, David – this is true for all liver disease, including fatty liver – when they have advanced liver disease, they're at increased risk for hepatocellular carcinoma. And it is thestandard of care, no matter how good they look, no matter how good their labs look, that we do liver cancer screeningwith ultrasounds every 6 months, and we often do a serum AFPlevel too. Now again, this is why patients with advanced liver disease should be sent to a specialist so we can start to implement these very important diagnostic and screening strategies.  

Well, this has certainly been a fantastic exploration of NAFLD and NASH. David, before we wrap up, what's your one key takeaway you'd like our primary care audience to remember from today's activity? 

Dr. Bernstein:   
Thanks, Steve. For me, the one takeaway is that this is very common, that primary care providers are going to see this every day, and with that, that patients, regardless of the degree of fibrosis, even cirrhosis, are usually asymptomatic and feel fine. So if you don't think about it and don't look for it, you're going to miss it. So my takeaway is: Think about it and look for it. 

Dr. Flamm:   
And my takeaway, David, is in keeping with yours, but I'm going to augment it a little bit. Not only is it common, because of the factors that lead to the development of fatty liver are so common, but it's frequently silent. It is developing and worsening right under the healthcare practitioner’s eyes if this isn't identified. So keep it in mind. If patients have elevated liver enzymes, they need to be taken very seriously. Even if they have normal liver enzymes, patients may have fatty liver. So have a low threshold to look for fatty liver with an ultrasound, and then calculate the fibrosis score, which is very easy. And don't have a false sense of security in patients that have fatty liver, again, that, as you said, they will see every day.  

Thank you, David, for joining me and for sharing all your valuable insights. It was great speaking with you today. 

Dr. Bernstein:  
Steve, thank you so much for having me. I enjoyed it.

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