Wrap-Up: Diabetes and Liver Disease: Exploring the Intersections and Best Practices

In this video, Carol Wysham, MD, provides an overview of the session "Diabetes and Liver Disease: Exploring the Intersections and Best Practices," at our Practical Updates in Primary Care 2023 Virtual Series, including the definition of non-alcoholic fatty liver disease (NAFLD), non-alcoholic fatty liver (NAFL), and non-alcoholic steatohepatitis (NASH), identifying risk factors and diagnostic tools for NAFLD, screening patients for type 2 diabetes, and more. 

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Carol Wysham, MD, is a clinical professor of medicine at the University of Washington School of Medicine and a clinical endocrinologist at MultiCare Rockwood Clinic (Spokane, WA). 

TRANSCRIPTION:

Carol Wysham, MD: My name is Dr. Carol Wysham, I'm a clinical professor of medicine at the University of Washington and a clinical endocrinologist at the Rockwood MultiCare Clinic.

So, the key takeaways from our presentation on non-alcoholic fatty liver disease and diabetes are that we should consider that at least 50% of our patients with type 2 diabetes, pre-diabetes, as well as those that have obesity and metabolic syndrome, are at risk for non-alcoholic fatty liver disease. We should consider screening all of our patients with type 2 diabetes. The consensus on how to screen is not at a hundred percent consensus, but certainly, we should consider an ultrasound of the upper abdomen. Using liver function tests for the screening is recommended, but we should consider that the upper limit of normal of the ALT and AST should be somewhere around 30 instead of the traditional 40, 50, or 60 that might exist on some chem profiles.

The American Diabetes Association, as well as the American Association of Clinical Endocrinologists, are recommending that we consider FIB-4 index calculations on all of our patients with diabetes. This score uses CBC, ALT, AST, and age to determine the risk for fibrosis. So if the patient has low risk, you just continue to monitor the patient, you do diet and exercise counseling, send them to a dietician, and really emphasize trying to find the best diet for them to lose weight. And then if they have intermediate or higher, then they probably need to see a gastroenterologist. I feel really comfortable just going ahead and ordering the elastography, and perhaps many of you have enough comfort and availability of that. You could certainly do that before making the decision about referring to gastroenterology.

And then, of course, it is appropriate to use certain antihyperglycemic therapies in your patients with diabetes and comorbid non-alcoholic fatty liver disease. And these include pioglitazone, the GLP-1 receptor agonists, and the newer GLP-1/GIP receptor dual agonists. And then finally, most importantly, is that the majority of patients with non-alcoholic fatty liver disease die of cardiovascular disease, not of liver-related complications, so these patients must have aggressive management of their atherosclerotic risk factors.

I hope you enjoyed the presentation. We certainly enjoyed giving it to you.