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An algorithm for the management of non-alcoholic fatty liver disease in primary care

Gastroenterology & Hepatology: Open Access
Amreen Dinani,1 Norman Sussman,2 Mazen Noureddin,3 Michael Fuchs,4 George Therapondos,5 Nigel Girgrah,5 Viviana Figueroa Diaz,6 Parvez Mantry,7 Mary Rinella,8 Amon Asgharpour,9 Douglas Dieterich1


Background:Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum of conditions from simple hepatic steatosis to non-alcoholic steatohepatitis (NASH), a condition that includes fat accumulation, inflammation, and cell death. The single factor that predicts early death in patients with NASH is hepatic fibrosis. Hence, early identification and risk stratification of individuals with NASH and fibrosis is essential.

Methods:A panel comprising 11 liver disease specialists was assigned sections of the manuscript to present at a consensus meeting in December 2019. The goal was to develop a care pathway for primary care providers (PCPs) to identify patients at risk for NAFLD, stratify risk, and refer those in need of specialty services.

Results:We developed a simple algorithm to identify risk factors for NAFLD and recognize patients with progressive hepatic fibrosis. Patients with obesity, type 2 diabetes, abnormal liver tests, or incidental findings of hepatic steatosis should be evaluated for NAFLD, hepatic fibrosis and cardiovascular risk using family history and accepted calculators (FIB-4 and ACC/AHA). Risk stratification includes cardiovascular and hepatic complications. Patients with ≥ stage 2 fibrosis by non-invasive testing should be referred to hepatologists. We recommend lifestyle interventions and medical management of comorbidities for patients with NAFLD. Patients should be followed long-term with assessment of liver status every 6 months.

Conclusions:Using this algorithm in a primary care setting may raise awareness of risk factors for NAFLD, encourage timely lifestyle interventions, promote appropriate prescribing habits, result in more effective use of specialist consultations, and improve patient outcomes.


AASLD, american association for the study of liver diseases, ACC/AHA, american college of cardiology/american heart association, ADA, american diabetes association, ALT, alanine aminotransferase, APRI, AST to platelet ratio index, AST, aspartate transaminase, AUDIT, alcohol use disorders identification test, BARD, BMI, AST/ALT ratio, diabetes, BMI, body mass index, EASD, european association for the study of diabetes, EASL, european association for the study of the liver, EASO, european association for the study of obesity, ELF, enhanced liver fibrosis, FIB-4, fibrosis-4 index, GLP-1, glucagon-like peptide-1, HbA1c, glycated haemoglobin A1c, HCC, hepatocellular carcinoma, NAFLD, non-alcoholic fatty liver disease, NASH, non-alcoholic steatohepatitis, NFS, NAFLD fibrosis score, NIT, non-invasive test, PCP, primary care provider, SGLT2i, sodium-glucose co-transporter-2 inhibitor, T2DM, type 2 diabetes mellitus, VCTE, vibration-controlled transient elastography