Management of Non-Alcoholic Fatty Liver Disease (NAFLD)

Introduction to NAFLD Management

The American Association for the Study of Liver Diseases recommends lifestyle modifications, including weight loss, Mediterranean diet, and exercise, as the cornerstone of NAFLD management, with pharmacotherapy reserved for biopsy-proven NASH with significant fibrosis 1, 2, 3
The European Association for the Study of the Liver and British Society of Gastroenterology also support this approach, emphasizing the importance of lifestyle interventions and careful selection of patients for pharmacotherapy 1, 4, 3, 5

The Korean Association for the Study of the Liver recommends that all NAFLD patients undergo lifestyle interventions aimed at 7-10% body weight loss through caloric restriction and increased physical activity 1, 3, 2, 6, 7
Weight loss targets include 5-7% weight loss to improve steatosis, 7-10% to improve inflammation and fibrosis, and >10% to achieve NASH resolution and fibrosis regression 3, 8, 6, 7
A dietary approach characterized by a Mediterranean diet, with reduced refined carbohydrates, avoidance of fructose-containing beverages, increased monounsaturated and omega-3 fatty acids, and high fiber intake, is recommended 9, 6, 7
Physical activity should include 150-300 minutes of moderate-intensity aerobic exercise weekly or 75-150 minutes of vigorous-intensity exercise, plus resistance training 3, 2, 6

Pharmacologic treatment should be reserved for patients with biopsy-proven NASH and significant fibrosis (stage ≥2), not for simple steatosis, as recommended by the American Association for the Study of Liver Diseases and European Association for the Study of the Liver 1, 4, 8, 2, 7
Guideline-supported pharmacotherapy options include vitamin E (800 IU/day) for non-diabetic patients with biopsy-proven NASH without cirrhosis, pioglitazone (30 mg/day) for patients with biopsy-proven NASH with or without diabetes, and GLP-1 receptor agonists (liraglutide, semaglutide) for patients with type 2 diabetes and NASH/fibrosis 3, 2, 7

All NAFLD patients should implement lifestyle modifications and treat metabolic comorbidities, with annual follow-up for low-risk patients and more frequent follow-up for high-risk patients 1, 2, 6
High-risk patients should be considered for liver biopsy and, if confirmed to have NASH with significant fibrosis, should be offered pharmacotherapy 3, 7
Cirrhotic patients should undergo HCC surveillance every 6 months with ultrasound ± AFP and variceal screening 2, 6

Rapid weight loss (>1 kg/week) should be avoided as it may worsen portal inflammation and fibrosis in some patients, as cautioned by the American Association for the Study of Liver Diseases and European Association for the Study of the Liver 1, 6
Statins are safe and should be used to treat dyslipidemia despite liver disease, according to the European Association for the Study of the Liver and British Society of Gastroenterology 3, 2
Metformin is not recommended as a specific treatment for NAFLD as it has no significant effect on liver histology, as stated by the American Association for the Study of Liver Diseases 6
Bariatric surgery should be considered for appropriate candidates with obesity and NAFLD, as it can achieve NASH resolution in up to 85% of patients, according to the European Association for the Study of the Liver and British Society of Gastroenterology 3, 5