Case 4: Management

Here are the results of the additional diagnostic testing:

FIB-4 Index: 1.36 points
 > Approximate fibrosis stage: Ishak 0-1
 > Low likelihood of advanced fibrosis

Transient Elastography:
 > 6.4 kPa (fibrosis score of F0-1)
 > CAP 333 / 400 (steatosis score of S3 – severe steatosis) 
 > IQR/med 13%


What are the 3 best next steps in management? 
Begin Vitamin E
Incorrect. Vitamin E administered at a daily dose of 800 IU/day improves liver histology in nondiabetic adults with biopsy-proven NASH. This patient is diabetic and does not have biopsy-proven NASH. 
Recommend weight loss of 7-10% body weight.
Correct! Weight loss of 7-10% is needed to improve the majority of the histopathological features of NASH, including fibrosis.
Begin Ursodiol
Incorrect. Ursodiol is not recommended for the treatment of NAFLD or NASH.
Resume Statin
Correct! Patients with NAFLD or NASH are not at higher risk for serious liver injury from statins. Thus, statins can be used to treat dyslipidemia in patients with NAFLD and NASH.
Schedule EGD to screen for varices
Incorrect. Patients with a liver stiffness <20 kPa and platelet count >150,000/mm3 have a very low probability (<5%) of having high-risk varices, and EGD can be circumvented.
Counsel the patient on the benefits of diet and exercise.
Correct! A combination of a hypocaloric diet (daily reduction by 500-1,000 kcal) and moderate-intensity exercise helps to provide the best likelihood of sustaining weight loss over time.

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