MANAGEMENT OF MASLD & MASH

Management of MASLD

The management of MASLD includes both treating the liver condition as well as the other associated or underlying metabolic disorders like insulin resistance, Type 2 diabetes, obesity and high fat levels in the blood.

Lifestyle Modification for Weight Reduction

The main goal of management of MASLD is weight loss. Lifestyle modification includes

Modification of diet
Physical activity – Exercise

Proven Benefits of Weight Loss in MASLD and MASH patients

Losing at least 10% of total body weight over a period can reverse MASLD and improves MASH
Losing ≥5% body weight stabilized or improved fibrosis
Prevents MASLD progression to more serious forms like fibrosis and MASH
Reverses the MASLD – simple fatty liver
Improved outcomes that are proportionate to improvement in liver condition in MASH patients

Diet Modification

Dietary modifications with calorie-restricted diet are recommended in patients who are over weight or obese to reduce weight and to improve metabolic disorders.

What is a Calorie-Restricted Diet?

Daily diet should be calorie deficient for example if a person needs total 2000 calories in day according to his BMI (proportion of weight to height) to sustain day-to-day activities or to maintain weight, the person should consume less than that.

Advantages of calorie-restricted diet in MASLD and MASH patients

Following a calorie restricted diet over a period will result in

Weight loss
Associated with mobilization of fat accumulated in the liver
Improves other associated metabolic disorders

Which is the recommended calorie-restricted diet?

There is no particular diet with particular proportions of macronutrients (carbs, proteins, fats) recommended for weight loss at present. But Mediterranean diet consisting of high amounts of fresh fruits, vegetables, olive oil and low amounts of protein is found to be beneficial in improving the fat content in the liver.

Exercise

Along with calorie restricted it advised to indulge in physical activity like walking, jogging, swimming and cycling to assist in weight loss and to improve metabolic disorders.

What should be the duration and intensity of exercise?

There is no recommended duration and intensity of exercise. But studies have shown that those who maintain a physical activity for more than 150 minutes per week and increase it every week have shown to improve their liver enzymes (ALT and AST) and metabolic disorders regardless of weight loss.

No alcohol consumption

Patients with MASLD are recommended not to take any alcohol of any type or amount.

Therapeutic Approach

Management with medicines is preserved only for MASLD patients

Diagnosed with MASH by biopsy
Presence of risk factors for MASH
Presence of fibrosis
To treat the underlying metabolic disorders, liver disease
To prevent outcomes of MASLD or MASH in the long-term

Management of Insulin resistance and Type 2 diabetes with Insulin Sensitizers

These are a group of drugs that are aimed at treating insulin resistance and other metabolic disorders associated with glucose and fat metabolism

Metformin: Metformin is recommended only in MASLD patients who are insulin resistant and Type 2 diabetic but not to treat MASH.
Thiazolidinediones: Among Thiazolidinediones, pioglitazone is found to improve liver condition in MASH patients with and without diabetes by improving insulin sensitivity, liver enzymes and fat content in the liver

Management of Dyslipidemia with Statins

Patients with MASLD have dyslipidemia a condition with high triglycerides and abnormal fat levels in blood that can contribute to worsening of MASLD and increased heart risk. Dyslipidemia in MASLD patients is treated with a category of drugs called statins that reduce the abnormal fat levels in blood and improve the elevated liver enzymes and reduce heart risks.

Omega-3 fatty acids

Omega-3 fatty acids are not specifically recommended to treat MASLD or MASH but are considered to treat hypertriglyceridemia (high levels of triglycerides) in patients with MASLD.

Management of Liver condition with Vitamin E (rrr α – tocopherol)

Vitamin E is considered as an anti-oxidant and its administration has shown to improve liver conditions like elevated liver enzymes, fat accumulation, cell death and inflammation of liver in MASH patients without Type 2 diabetes. Risks and benefits are assessed carefully before starting the treatment with Vitamin E. It is to be noted that Vitamin E is not recommended in MASLD patients without biopsy, MASH patients with diabetes and MASH cirrhosis or cryptogenic cirrhosis.

Surgical Approach

Bariatric Surgery

Bariatric surgery is a type of surgery done to reduce weight by reducing the capacity of food intake.

Various types of bariatric surgery used for weight loss

Gastric band
Sleeve gastrectomy
Gastric bypass

Bariatric surgery is recommended in

Heavily obese and overweight patients with risk factors
Patients who can not lose by physical exercise and calorie restricted diet due to weight and other co-existing disease conditions

Advantages of bariatric surgery in MASLD and MASH patients

Reduction of weight
Improve MASLD , and associated metabolic disorders
Improves long-term survival and reduce the heart related disorders

Liver Transplantation

Liver transplantation is done only in

MASH patients with cirrhosis
End stage liver failure

Considerations for Liver transplantation

Lot of factors like obesity and other associated risk factors like heart and kidney complications are thoroughly studied before the surgery. As most of the MASH patients are severely obese, weight loss through diet and exercise are recommended before the surgery and are recommended to maintain weight after the surgery for improved and sustained outcomes.

Reference:

Chalasani, N. , Younossi, Z. , Lavine, J. E., Charlton, M. , Cusi, K. , Rinella, M. , Harrison, S. A., Brunt, E. M. and Sanyal, A. J. (2018), The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology, 67: 328-357. doi:10.1002/hep.29367