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AGA ISSUES IMPRACTICAL FATTY LIVER RECOMMENDATIONS
illustration of fatty liver

November 22, 2021 - The AGA recently issued recommendations on the screening, diagnosis, and treatment of nonalcoholic fatty liver disease (NAFLD). The guidelines are outlined in a "Clinical care pathway" intended for primary care providers, endocrinologists, gastroenterologists, and obesity specialists. Highlights from the guidelines include the following:

  • Screen all patients with metabolic risk factors (e.g. hypertension, low HDL, obesity), type 2 diabetes, liver steatosis on imaging, or elevated LFTs for NAFLD
  • Patients with FIB-4 score ≥ 1.3 should be referred for liver stiffness measurement (Fibroscan)
  • Patients with FIB-4 score ≥ 1.3 and/or Fibroscan score ≥ 8 kPa should be referred to a hepatologist for further management

While these recommendations may be great for filling up gastroenterologist practices, they are mostly impractical. Obesity is so widespread that abnormal liver enzymes have become routine. The number of patients in a typical primary care practice these guidelines encompass is substantial. For example, according to the recommendations, a fifty-year-old with an AST of 42, ALT of 30, and platelet count of 170,000 (FIB-4 of 2.26) would be referred for a Fibroscan. The same patient with an AST of 51 (FIB-4 of 2.74) would be considered "high risk" and referred to hepatology. [Link to guidelines]

Since no therapies have been FDA-approved to treat NAFLD, their treatment algorithm can be summed up in two simple words - weight loss.

The AUA guidelines are unreasonable and inefficient. Providers should approach abnormal liver enzymes using the 2017 ACG recommendations. Once other treatable conditions have been ruled out, patients with NAFLD should focus on weight loss.


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