Management of Fatty Liver Disease and Cirrhosis

Pharmacological and Supplemental Interventions

The American Association for the Study of Liver Diseases recommends administering vitamin E 800 IU daily specifically to non-diabetic adults with biopsy-confirmed NASH without cirrhosis 1, 2, 3, 4
The American Gastroenterological Association suggests that vitamin E improves liver histology through antioxidant properties and has demonstrated resolution of steatohepatitis in randomized trials 5, 4
The American Diabetes Association advises against using vitamin E in patients with type 2 diabetes, as trial results were mixed in this population 5
The European Association for the Study of the Liver recommends against using vitamin E in patients with established cirrhosis 2
The American Association for the Study of Liver Diseases recommends prescribing pioglitazone 30 mg daily for patients with biopsy-proven NASH who have type 2 diabetes, with or without cirrhosis 2, 3, 4
The American Gastroenterological Association suggests that pioglitazone improves all histological features of NASH except fibrosis 4
The European Association for the Study of the Liver recommends using BCAA supplements in decompensated cirrhotic patients to achieve adequate nitrogen intake 6, 7

The European Society for Clinical Nutrition and Metabolism recommends administering BCAA supplements specifically to malnourished patients with decompensated cirrhosis 6, 7
The American Gastroenterological Association suggests that these supplements help achieve the recommended protein intake of 1.2–1.5 g/kg body weight per day 6, 7
The European Association for the Study of the Liver recommends including late evening oral nutritional supplementation (containing BCAAs) along with breakfast in the dietary regimen of malnourished decompensated cirrhotic patients 6, 7

The American Association for the Study of Liver Diseases recommends against prescribing liver-directed pharmacotherapy or supplements for simple steatosis or early NASH (F0-F1 fibrosis) 3, 4
The American Gastroenterological Association suggests that lifestyle modifications, such as 7-10% weight loss, Mediterranean diet, and 150-300 minutes of moderate-intensity exercise weekly, are recommended for simple steatosis or early NASH (F0-F1 fibrosis) 3, 4
The European Association for the Study of the Liver recommends requiring liver biopsy confirmation before initiating vitamin E or pioglitazone for advanced NASH (F2-F3 fibrosis) 1, 3, 4

The American Association for the Study of Liver Diseases recommends that patients receiving vitamin E or pioglitazone should be managed by a hepatologist-coordinated multidisciplinary team 5, 3
The American Gastroenterological Association suggests that monitoring for disease progression with FIB-4 scores and liver stiffness measurements every 6 months to 2 years is recommended 2
The European Association for the Study of the Liver recommends screening for hepatocellular carcinoma with ultrasound ± AFP every 6 months in cirrhotic patients 2, 4