ADA Releases Guidelines Update for Screening and Treatment NAFLD in Type 2 Diabetes, Check Out Details

Liver disease affects up to 70% of people with T2DM. Given the close pathophysiological relationship between the two diseases, there is a prudent need to consider an aggressive multipronged treatment approach for managing T2DM with NAFLD.

The new recommendations released in the latest issue of Standards of Care in Diabetes—2023, are based in the light of the latest scientific research and clinical trials.

On the treatment side, the new update recommends Pioglitazone or glucagon-like peptide 1 receptor agonists as the preferred agents for the treatment of hyperglycemia in adults with type 2 diabetes with biopsy-proven non-alcoholic steatohepatitis, or those at high-risk for non-alcoholic fatty liver disease with clinically significant liver fibrosis using noninvasive tests. (Level of Evidence A)

In addition, insulin therapy is recommended for the treatment of hyperglycemia in adults with T2DM with decompensated cirrhosis. (Level of Evidence C)

The guidelines also provide detailed recommendations for screening and diagnosis, emphasizing on the following:

• In adults with diabetes or prediabetes with persistently elevated plasma aminotransferase levels for >6 months and low fibrosis-4 index should be evaluated for other causes of liver disease. (Level of Evidence B),
• Adults with diabetes or prediabetes with indeterminate or high fibrosis-4 index should have additional risk stratification by liver stiffness measurement with transient elastography, or the blood biomarker-enhanced liver fibrosis. (Level of Evidence B)
• Adults with diabetes or prediabetes with indeterminate results or at high risk for significant liver fibrosis (i.e., by fibrosis-4 index, liver stiffness measurement, or enhanced liver fibrosis) should be referred to a gastroenterologist or hepatologist for further workup. (Level of Evidence B)

Indian Practitioner’s Perspective

Screening Perspective:

The emergence of India as a rapidly growing economy with easy access to calorie-dense food and a sedentary lifestyle together with the modern epidemics of diabetes mellitus (DM) and obesity have catapulted nonalcoholic fatty liver disease (NAFLD) into a substantial public health problem in India. NAFLD has emerged as one of the leading causes of cirrhosis, hepatocellular carcinoma (HCC), and liver transplant in India.

Fibrosis is the strongest predictor for long‐term clinical outcomes among patients with non‐alcoholic fatty liver disease (NAFLD). The FIB‐4 scoring system has demonstrated the ability to risk stratify patients for liver‐related morbidity and mortality.

Treatment Perspective:

Among the recommended treatment options, Pioglitazone is one of the most cost-effective agents and could be an appropriate practical consideration for the management of hyperglycemia in adults with type 2 diabetes with biopsy-proven non-alcoholic steatohepatitis among Indian patients.

Adapted from

Standards of Care in Diabetes-2023. Diabetes Care 2023 Addendum. 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes—2023. Diabetes Care 2023;46(Suppl. 1):S49–S67. Access on 28th June 2023.