Fatty Liver (cont.)
Bhupinder Anand, MD
In this Article
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NAFLD has been associated in human or animal studies with reduced amounts of unsaturated fats (a diet high in saturated fat) and increased amounts of fructose (which is most commonly added to the diet as high-fructose corn syrup). Benefits of increasing unsaturated fat (a diet lower in saturated fat, and higher unsaturated fat) and reducing high fructose corn syrup on NAFLD have not been demonstrated; however, there is little harm in doing so, especially since there may be benefits of these dietary modifications unrelated to the liver.
An interesting observation - though unexplained - is that there is less scarring (fibrosis) in the livers of patients with NASH who drink more than two cups of coffee per day. (Scarring or fibrosis is the process that ultimately leads to cirrhosis.) Similar benefits of coffee have been associated with lesser degrees of liver disease in both alcoholic cirrhosis and hepatitis C. It is not unreasonable to recommend drinking coffee in moderate amounts in view of the lack of harmful side effects.
Vitamin D deficiency is associated with NAFLD. Although there is no reason to think that this deficiency contributes to NAFLD, it is reasonable to measure vitamin D levels in patients with NAFLD and treat them with vitamin D if they are deficient.
There is no evidence of harmful effects of light alcohol consumption (two or fewer drinks per day) on NAFLD though there also is no evidence that it is safe! Larger amounts of alcohol consumption should be avoided by everyone, including individuals with NAFLD.
Medications and other treatment options
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Metformin (Glucophage) is a drug used for treating diabetes. It works by increasing the insulin sensitivity of cells, directly counteracting the insulin resistance that accompanies NAFLD as well as the metabolic syndrome. It has been studied but, unfortunately, has not been found to improve the liver injury associated with NASH.
Pioglitazone (Actos) and rosiglitazone (Avandia) are drugs that also are used for treating diabetes because they increase insulin sensitivity. There has been a reduction in liver fat and signs of liver injury with both drugs, and pioglitazone might reduce the scarring that results from the inflammation of NASH. Two problems that occur with treatment are weight gain and, with rosiglitazone, an increase in heart attacks. Pioglitazone may be used to treat NASH; however, it needs to be recognized that its long-term effectiveness and safety have not been well-established.
Vitamin E has been studied in NASH because of its general effects of opposing inflammation. It has been shown to reduce liver fat and inflammation and possibly fibrosis, but its long-term effectiveness and safety have not been well-studied. Moreover, treatment of patients with vitamin E who do not have NASH is associated with a higher mortality. Vitamin E can be used for treating NASH, but it should be used selectively (not in all patients), and patients should understand the potential risk.
Pentoxyfylline (Trental) has been studied for the treatment of NASH in small groups of patients with encouraging results; however, there is not enough experience or knowledge of its effectiveness and safety to recommend treatment outside of research studies.
Small studies have shown some benefit with omega-3-fatty acids in reducing liver fat in NAFLD, and larger studies are underway. In large groups of individuals (not selected because of the presence or absence of NAFLD), omega-3-fatty acids were shown to reduce cardiovascular events such as heart attacks and overall mortality. Therefore, omega-3-fatty acids may be appropriate treatment for patients with NAFLD and the metabolic syndrome because these patients have a high incidence of cardiovascular disease and death.
Lipid-lowering drugs, specifically the statins and ezetimibe (Zetia), have been used to treat the abnormal blood lipids associated with the metabolic syndrome. Although there is evidence of beneficial effects of these drugs on the liver in NAFLD, there is not enough experience to recommend them in patients with NAFLD unless they are primarily being used for treating abnormal blood lipids.
Ursodeoxycholic acid (Ursodiol) has been studied in NAFLD but has been abandoned because of its ineffectiveness and concerns about toxicity at very high doses.
Medically Reviewed by a Doctor on 7/9/2014
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