Issue: August 2021
Source: Healio interview
August 23, 2021
4 min read

Beyond awareness: We need a ‘recipe for health’ in metabolic syndrome

Issue: August 2021
Source: Healio interview
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This month’s cover story puts forth a call to action for our fellow physicians to be more aware of fatty liver disease risk. But this call needs to be about more than awareness. It must be a call for multidisciplinary coordinated screening and follow-up.

Looking at NASH in particular, we know that about 70% of patients with NASH also have diabetes. Theoretically, we might assume that those patients will then be screened for cardiovascular risk despite us not knowing what concomitant NASH and diabetes might confer.

Nancy S. Reau, MD, FAASLD, AGAF
Nancy S. Reau

Yet in looking at UpToDate (Wolters Kluwer) and other resources, they do not recommend additional screening for CV disease in patients with diabetes and controlled lipids and hypertension. The reason: it wouldn’t change management. I’m not sure that is true.

If a patient has high cholesterol and hypertension, you’re going to treat those two things, but are there guidelines when they should also have CT calcium scores or additional stress testing?

If you’re making a call to action for multidisciplinary care, you need a coordinated algorithm on what to do, when to do it and who takes the lead in a patient’s risk profile.

Identifying Risk

We as medical societies must identify a path to those who are likely to have a cardiovascular event even with good glycemic, lipid and BP control or those who are at highest risk for a liver-related event despite not having treatment options specific to NAFLD.

When we work on coordinated multidisciplinary care, we must have a multidisciplinary algorithm. You cannot have the American Diabetes Association recommending one thing, the American Heart Association recommending another and AASLD forging its own path, because our patients enter care through any one of these pathways.

All our patients likely have an endocrinologist or diabetologist, maybe a lipid specialist. They might have a cardiologist. When we see them in hepatology or GI, they are getting a fatty liver disease expert who is not aware of the other society’s recommendations. We need to have a path that identifies important interventions including when to get a subspecialist involved.

Currently, as a hepatologist, if I see an HbA1c is 12, I will send a letter to the person caring for their diabetes. But maybe that’s not good enough. Maybe I should be encouraging the patient to discuss with their PCP that they need to have subspecialized management for their diabetes. Maybe I need to have the skill set to say, “This agent may be important, you should discuss it with your diabetes management team.”

When to Drive, When to Support

If a patient enters our subspecialty care with fatty liver disease, but doesn’t have advanced fibrosis, their management now is multidisciplinary, but we are not the driver. We are in the backseat because their liver-related risk is quite low. Today, we might say that to the patient and instruct them to return in 2 years.

But maybe we should be plugging them into an algorithm where we input their hyperlipidemia, sleep apnea, PCOS, poorly controlled diabetes, hypertension, etc. and change our message. Perhaps it becomes, “Right now, your liver-related risk is low, and we will reassess that in 2 years, but you need to concentrate on these five things. This is your recipe for health.”

On the other hand, if you have a person who enters the pathway and you perform a Fibroscan (Echosens) and they have advanced fibrosis, then you become a front-seat passenger, if not the driver. You need to coordinate with the multidisciplinary care team and say, “I realize all these other things are important, but your patient has an increased risk for a liver-related complication.”

Those physicians must encourage the patient to return to the gastro-hep clinic and keep their liver risks front of mind.

The other subspecialists on this coordinated path need to remember that this person needs liver cancer screening. They might need an endoscopy to screen for esophageal varices. This person is at higher risk for advancing their liver disease risk with uncontrolled diabetes. Maybe their diabetic drug prescription may need to be different, using certain agents over others.

This is where AASLD can be helpful in helping other specialists to know which drugs might also have liver-related benefit and which might have liver-related contraindication.

We are still waiting on the HCV-equivalent fatty liver guidelines from our societies. Ideally, you should have a coordinated GI-hepatology approach to fatty liver disease. With those, we can start to carve out the role of the hepatologist or gastroenterologist and then develop multidisciplinary guidelines in conjunction with other key players.

Hepatologists have been frustrated by the other societies completely ignoring fatty liver disease. That’s no longer true. Now, some of the diabetes guidelines do recommend screening for steatosis in patients with diabetes. But it should be all of them.

If you have any component of metabolic syndrome, you should be screened for fatty liver disease. Our role is to offer a guide for that screening and outline when a patient needs to see a hepatologist or gastroenterologist.

Personalizing Our Approach

It’s important to recognize that we still do not fully understand the epidemiology of NAFLD. Although we say that one-third of Americans have fatty liver and one-tenth of pediatric Americans have fatty liver, we don’t actually know how it works within the metabolic syndrome.

We know that diabetes and fatty liver together increase the risk for liver-related risk over fatty liver alone, but what does concomitant steatosis do to cardiovascular risk when they also have diabetes and hypertension?

We don’t know these answers. We might know some from NHANES or Framingham, but America is big and heterogenous. Ethnicity and predisposition are also adding to this risk assessment. How do we personalize our approach and tell the person in front of us what their risk is? We still need more data; we need to work on a coordinated effort on how to capture what true risk is.

We recognize that fatty liver is prevalent, and a subset is very dangerous, but we struggle to identify which of these patients need liver-centric care vs. which need to prioritize cardiovascular or diabetes care.

There are patients who end up losing kidneys or eyesight due to diabetes and never develop liver disease. There are others who look healthy but have metabolic syndrome and they come in with hepatocellular carcinoma because they were never screened.

How do you find where to concentrate your efforts on that person’s health? Only through a joint effort to coordinate care, screening and guidance can we find the individual pathways to preventive and curative health.