Medications and other treatment options
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 nonalcoholic fatty liver disease as well as the metabolic syndrome. It has been studied but, unfortunately, has not been found clearly 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.
Pentoxifylline (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 nonalcoholic fatty liver disease, and larger studies are underway. In large groups of individuals (not selected because of the presence or absence of nonalcoholic fatty liver disease), 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 nonalcoholic fatty liver disease 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 nonalcoholic fatty liver disease, there is not enough experience to recommend them in patients with nonalcoholic fatty liver disease unless they are primarily being used for treating abnormal blood lipids.
Ursodeoxycholic acid (Ursodiol) has been studied in nonalcoholic fatty liver disease but has been abandoned because of its ineffectiveness and concerns about toxicity at very high doses.