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Kurdistan Board GEH J Club:Supervised by:

Dr. Mohamed AlshekhaniProfessor in Medicine

MBChB-CABM-FRCP-EBGH 2016

Introduction:• NAFLD is the most common liver disorder in the world.• NAFLD is pandemic with prevalence of 20–30% in West , 5–18% in

Asia&increase over time due to changes in dietary habits towards westernized style &increase of sedentary lifestyle.

• Treatments needed BZ of 1.7 fold increase in standardized age/ ‑gender matched mortality.‑

• The most common cause of death in NAFLD &NASH is CVD& incr liver related mortality sp with advanced fibrosis,cirrhosis & HCC.‑

• Currently,no medicine is the standard of care& available drugs targeting the established pathophysio of NASH with the associated disease, remains experimental withiout evidence based support. ‑

• The need for an effective agent is high,sp when NAFLD is isolated. • Until then, trt focus on lifestyle, medicines for associated

conditions& probably liver protecting agents. ‑

Management: wt loss

• Weight loss of at least 7% is effective in improving histological disease activity, but achieved by < 50%.

• More wet loss (10%) needed to improve necro inflammation.‑• It is through carbohydrate & lipid restriction. • The Mediterranean dietary pattern has gained interest.• Severe caloric restriction should be avoided, as it may be harmful &

lead to decompensation of liver function & aggravating NAFLD.

Management: PA

• Improving physical activity is the most powerful to correct metabolic indices&elevated liver enzymes

• . Patients who could perform a 150 to 300 min exercise /week for ‑ ‑16 weeks had a significant improvement in their hepatic steatosis.

• Aerobic & endurance exercises have a positive impact on steatosis even if the patient could not lose weight.

Management: Orlistat

• It should be discontinued after 12 weeks if patients have been unable to lose at least 5% of the body weight &treatment duration should not be >1 year as there is potential for fat soluble vitamin ‑deficiency.

Management: Cofee

• Its beneficial effects observed in multiple chronic conditions as T2DM,Parkinson disease, prostate cancer, HCV,HCC&NAFLD.

• increasing coffee intake is associated with a modest decrease in all cause mortality.‑

• Coffee has inverse relationships with both T2DM&hepatic fibrosis in patients with NAFLD.

• Coffee intake was shown to be inversely associated with advanced fibrosis among NAFLD patients with lower HOMA IR.‑

Conclusion:• There is no single medication recommended as a target specific ‑

agent for routine clinical use in NAFLD. • The best available treatment is a reasonable dietary plan &tailored

exercise program with drugs for any associated comorbid disease with a specific medicine from the list of medications.

• Liver protection is an important part of the plan as EPL or sylimarin. • EPL is as an important additive nutr support with favorable effect. • No evidence to support the use of medicines that were long used on

empiric basis such as vitamin E, UDCA, SAMe.• Drugs for fibrosis caused by NASH is not convincing, although

pentoxyfylline may have some effect&anti lysyl oxidase monoclonal ‑antibodies, may be the choice.

• New: OCA, GFT505, metreleptin,pradigastat , probiotics are hopful.• Testosterone indicated for hypogonadal men. • For very obese, surgery may improve NASH but? long term.‑