Links To And Excerpts From The Curbsiders’ “#452 NAFLD/MASLD with Dr. Elliot Tapper” With Links To Additional Resources

Posted on September 25, 2024 by Tom Wade MD

In addition to today’s resource, please review the following resources on liver tests:

Today, I link to and excerpt from The Curbsiders‘ #452 NAFLD/MASLD with Dr. Elliot Tapper.*

*Achi, SS, Tapper, EB Williams PN, Watto MF. “#452 NAFLD/MASLD”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast 09 September Day, 2024.

All that follows is from the above resource.

Here are Dr. Tapper’s take-home points:

All right [Dr. Tapper], then if you would uh one or two take-home points that you really want the audience to remember

or two or three if you if you need okay so there are two main responsibilities when

you are faced with somebody who likely has fat in their liver and elevated liver enzymes.  The first is to provide

them a specific diagnosis which includes excluding alcohol use disorder and two a

prognosis through the sequential application of tests that can identify a risk for advanced fibrosis and the ones

that you use are the FIB 4 fib4 and then most likely elastography

usually through Vibration Controlled Transient Elastography (VCTE) or failing that a serologic test like the

enhanced liver fibrosis test. I think we can do this. Paul, we’ve we’ve got this.

You know some of the patients are going to end up getting [to see Dr. Tapper] but I think we can do a lot of

work before they get to him yeah for sure

Sep 9, 2024 Full Episodes

Expand your NAFLD/MASLD knowledge! Expert guest Dr. Elliot Tapper (@ebtapper) shares his framework for approaching NAFLD/MASLD and the treatment tools he recommends including lifestyle modifications and medications.

Show Segments

  • Intro
  • Rapid Fire Segment
  • Case 1 Part 1
  • NAFLD/MASLD terminology and differential diagnoses
  • PEth testing
  • Diagnostic tools for NAFLD/MASLD: Fib4 Score
  • Imaging
  • When to Refer to a Hepatologist?
  • Treatment options
  • Lifestyle modifications
  •  Role of GLP-1 agonists
  • Role of new FDA approved medications
  • Outro

[NAFLD/MASLD] Pearls

  1. Patients diagnosed with NAFLD/MASLD should be given this specific diagnosis along with a prognosis– their long term prognosis is determined by the extent of fibrosis.
  2. Fib4 score is a tool/algorithm that can be used for prognosis.  The score is comprised of: age, platelet count, AST, and ALT levels
  3. Imaging modalities such as the vibration controlled transient elastography have replaced the need for liver biopsy.
  4. Weight loss has the potential to reduce and even resolve fibrosis.
  5. Newer medications are on the horizon for NAFLD/MASLD treatment such as Resmetirom.*

*NEJM Study Highlights Resmetirom’s Efficacy in NASH With Liver Fibrosis. MedScape. Becky McCall. February 07, 2024

*FDA Approves First Treatment for Patients with Liver Scarring Due to Fatty Liver Disease. March 24, 2024.

*Vibration-controlled Transient Elastography in NAFLD: Review Study. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Euroasian J Hepatogastroenterol. 2022 Jul;12(Suppl 1):S41-S45. doi: 10.5005/jp-journals-10018-1365.

There are 109 similar articles in PubMed.

The above article has been cited by seven articles in PubMed.

NAFLD/MASLD Show Notes 

NAFLD/MASLD terminology 

MASLD (metabolic dysfunction-associated steatotic liver disease) is the new terminology that has replaced NAFLD (non-alcoholic fatty liver disease) or MAFLD (metabolic dysfunction associated fatty liver disease) (Portincasa 2024). It is one of the most common chronic liver conditions in the world and prevalence is estimated to be about 30% (Angulo 2015, Younossi 2023).

History and Physical Exam 

Dr. Tapper says that the main things to do when a patient comes in with abnormal liver function tests +/- “fat” on imaging are:

  1. Provide a diagnosis (think about the differentials): consider alcohol use disorder, hepatitides, medications, and other rare causes of abnormalities
  2. Provide a prognosis (assess for fibrosis): assess risk of fibrosis (eg Fib4 score) and consider imaging

Differential Diagnoses

The majority of steatosis cases are due to metabolic dysfunction or alcohol use and a small fraction are due to medications,  hepatitides, and autoimmune disease.

Alcohol Use  

When asking about alcohol use, the provider must foster a safe environment for the discussion.  Dr. Tapper may order a PEth (Phosphatidylethanol) level for an objective assessment of alcohol use. PEth is a phospholipid that only forms in the presence of ethanol and its presence is not affected by hypertension or kidney disease. Studies have shown that it is a highly sensitive and specific test up to 4 weeks post alcohol use, with a cutoff value of 20 ng/ml for positive test (Hahn 2023) (Viel 2012).

Hepatitis B, Hepatitis C, other diseases

Review the USPSTF guidelines and screen patients who are at risk of hepatitis B with detailed history questions and appropriate serological testing. All people ages 18-79 should be screened for hepatitis C and treated if infected (US Preventive Task Force guidelines 2020)

Dr. Tapper also recommends screening for alcohol use disorder, counseling about reducing alcohol consumption, and reviewing diet and exercise improvements.  If liver function test abnormalities persist despite these interventions, he will evaluate for other diagnoses such as autoimmune hepatitis. In situations where the ALT is >200s, he often employs additional testing for conditions such as autoimmune hepatitis* and may be quicker to arrange a liver biopsy.

*Please review the following resources for autoimmune hepatitis:

 

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