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Clinical Issues™

Identifying NASH in Patients With Diabetes

What You Need to Know

Meeting Slides

Clinical Practice Guidelines

The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Association for the Study of Liver Diseases.

Chalasani N, et al. Hepatology. 2018;67(1):328-357.

EASL–EASD–EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease.

European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD), and European Association for the Study of Obesity (EASO). J Hepatol. 2016;64(6):1388-1402.

Clinical Resources

Histological Scoring System for Nonalcoholic Fatty Liver Disease.

Transplant Pathology Internet Services, 2009.

MELD Score (Model for End-Stage Liver Disease) (12 and older).

MD+CALC online calculator, 2016.

NAFLD (Non-Alcoholic Fatty Liver Disease) Fibrosis Score.

MD+CALC online calculator.

Fibrosis-4 (FIB-4) Index for Liver Fibrosis.

MD+CALC online calculator.

AST to Platelet Ratio Index (APRI).

MD+CALC online calculator.

Patient Resources

American College of Gastroenterology (ACG) Patient Education and Resource Center.

The ACG website provides a basic overview of NAFLD and includes patient-centered podcasts.

American Liver Foundation.

The American Liver Foundation website offers broad-based information and links to additional educational resources and support services for patients living with liver disease.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Health Information Center.

The NIDDK website for NAFLD and NASH provides comprehensive patient-centered information and resources, including an overview of clinical trial participation.

Suggested Readings

Nonalcoholic fatty liver disease incidence and impact on metabolic burden and death: a 20 year-community study.

Allen AM, et al. Hepatology. 2018;67(5):1726-1736.

Liraglutide safety and efficacy in patients with non-alcoholic steatohepatitis (LEAN): a multicentre, double-blind, randomised, placebo-controlled phase 2 study.

Armstrong MJ, et al. Lancet. 2016;387(10019):679-690.

Non-alcoholic fatty liver disease: an expanded review.

Benedict M, Zhang X. World J Hepatol. 2017;9(16):715-732.

Management of nonalcoholic fatty liver disease in patients with type 2 diabetes: a call to action.

Bril F, Cusi K. Diabetes Care. 2017;40(3):419-430.

The multiple-hit pathogenesis of non-alcoholic fatty liver disease (NAFLD).

Buzzetti E, et al. Metabolism. 2016;65(8):1038-1048.

Combination therapy of metformin and statin may decrease hepatocellular carcinoma among diabetic patients in Asia.

Chen HH, et al. Medicine (Baltimore). 2015;94(24):e1013.

Role of obesity and lipotoxicity in the development of nonalcoholic steatohepatitis: pathophysiology and clinical implications.

Cusi K. Gastroenterology. 2012;142(4):711-725.

Long-term pioglitazone treatment for patients with nonalcoholic steatohepatitis and prediabetes or type 2 diabetes mellitus: a randomized trial.

Cusi K, et al. Ann Intern Med. 2016;165(5):305-315.

Effect of canagliflozin treatment on hepatic triglyceride content and glucose metabolism in patients with type 2 diabetes.

Cusi K, et al. Diabetes Obes Metab. 2018;21(4):812-821.

Increased risk of mortality by fibrosis stage in nonalcoholic fatty liver disease: systematic review and meta-analysis.

Dulai PS, et al. Hepatology. 2017;65(5):1557-1565.

Components of metabolic syndrome increase the risk of mortality in nonalcoholic fatty liver disease (NAFLD).

Golabi P, et al. Medicine (Baltimore). 2018;97(13):e0214.

Noninvasive imaging methods to determine severity of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

Hannah WN Jr, Harrison SA. Hepatology. 2016;64(6):2234-2243.

A meta-analysis of randomized trials for the treatment of nonalcoholic fatty liver disease.

Musso G, Gambino R, Cassader M, Pagano G. Hepatology. 2010;52(1):79-104

Non-alcoholic fatty liver disease.

Neuschwander-Tetri BA. BMC Med. 2017;15(1):45.

Elafibranor, an agonist of the peroxisome proliferator-activated receptor-α and -δ, induces resolution of nonalcoholic steatohepatitis without fibrosis worsening.

Ratziu V, et al. Gastroenterology. 2016;150(5):1147-1159.

Cenicriviroc treatment for adults with non-alcoholic steatohepatitis: year 2 analysis of the phase 2b CENTAUR study.

Ratziu V, et al. J Hepatol. 2018;68(suppl 1):S1-S2.

Management of NAFLD: a stage-based approach.

Rinella ME, Sanyal AJ. Nat Rev Gastroenterol Hepatol. 2016;13(4):196-205.

Treatment of NAFLD with diet, physical activity and exercise.

Romero-Gómez M, et al. J Hepatol. 2017;67(4):829-846.

Diagnosis of fibrosis and cirrhosis using liver stiffness measurement in nonalcoholic fatty liver disease.

Wong VW, et al. Hepatology. 2010;51(2):454-462.

Positive results from REGENERATE: a phase 3 international, randomized, placebo-controlled study evaluating obeticholic acid treatment for NASH.

Younossi Z, et al. J Hepatol. 2019;70(suppl 1):e5.

Relevant Resources

Incretin-Based Therapies for Type 2 Diabetes

Mechanism-Based Strategies to Achieve Patient-Centered Care

Insulin Replacement Therapy for Type 2 Diabetes

Patient-Centered Management of Hyperglycemia in Primary Care

Improving Outcomes in Type 2 Diabetes

Integrating GLP-1 Receptor Agonists Into Multimodal Treatment Regimens

A Focus on Bipolar Depression

Overcoming Diagnostic Barriers and Optimizing Long-Term Patient Outcomes

Clinical Issues in Type 2 Diabetes

Discussions and Debates Around GLP-1 Receptor Agonists

Clinical Issues in Type 2 Diabetes

Evolving Roles of GLP-1 Receptor Agonists

Improving Outcomes for Women with Type 2 Diabetes

Individualizing Evidence-Based Care

Noninsulin Approaches to Managing Type 2 Diabetes

Best Practices in Combination Therapy

Hitting the Target in Type 2 Diabetes

Evolving Approaches to Insulin Based Therapy

Improving Outcomes in Congenital and Acquired Lipodystrophy

Best Practices in Diagnosis and Management

Clinical Updates in Type 2 Diabetes

New Strategies for Insulin Replacement Therapy

Clinical Issues in Type 2 Diabetes

Consensus and Controversies Around Intensifying Noninsulin Therapy

How Low Do You Go?

Clinical Updates in LDL-C Management

Incretin-Based Therapies For Type 2 Diabetes

Improving Comprehensive Patient Care

Clinical Updates in Type 2 Diabetes

An Evolving Role for Combinations of Injectable Antihyperglycemic Therapies

Raising the Bar by Lowering the Target

Integrating PCSK9 Inhibitors Into Hypercholesterolemia Management

Injecting New Ideas into Managing Type 2 Diabetes

Evolving Roles of GLP-1 Receptor Agonists

Multidimensional Issues in Type 2 Diabetes

Looking Beyond Hemoglobin A1c

GLP-1 Receptors Agonists in Type 2 Diabetes

Mechanistic Insights and Evolving Treatment Options

Pharmaceutical Economics and LDL-C Management

Implications for PCSK9 Inhibitors in Clinical Practice

Assimilating the Evidence in T2DM

Cardiovascular and Renal Outcomes With SGLT2 Inhibitors

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SHOW COLUMNS FROM `interactions`
 1 0.001008 0.001008 0.001008 0.001008
select id from resources where FIND_IN_SET(:shortAddress, shortAddress)
 2 0.000983 0.000491 0.000358 0.000625
SELECT * FROM `resources` `t` WHERE `t`.`id`=118 LIMIT 1
 1 0.000540 0.000540 0.000540 0.000540
SHOW CREATE TABLE `interactions`
 1 0.000366 0.000366 0.000366 0.000366
SHOW CREATE TABLE `resources`
 1 0.000297 0.000297 0.000297 0.000297
SHOW CREATE TABLE `activities`
 1 0.000284 0.000284 0.000284 0.000284
SHOW CREATE TABLE `users`
 1 0.000264 0.000264 0.000264 0.000264
# Query Time (s)
0
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
 0.000933
1
select id from resources where FIND_IN_SET(:shortAddress, shortAddress)
 0.000625
2
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
 0.003583
3
select id from resources where FIND_IN_SET(:shortAddress, shortAddress)
 0.000358
4
SHOW COLUMNS FROM `resources`
 0.004604
5
SHOW CREATE TABLE `resources`
 0.000297
6
SELECT * FROM `resources` `t` WHERE `t`.`id`=118 LIMIT 1
 0.000540
7
SHOW COLUMNS FROM `interactions`
 0.001008
8
SHOW CREATE TABLE `interactions`
 0.000366
9
SHOW COLUMNS FROM `resource_videos`
 0.001173
10
SHOW CREATE TABLE `resource_videos`
 0.004434
11
SELECT `videos`.`id` AS `t1_c0`, `videos`.`vzaar_id` AS `t1_c1`, `videos`.`title` AS `t1_c2`, `videos`.`description` AS `t1_c3`, `videos`.`resource_id` AS `t1_c4`, `videos`.`type` AS `t1_c5` FROM `resource_videos` `videos` WHERE (`videos`.`resource_id`=:ypl0)
 0.004418
12
SHOW COLUMNS FROM `activities`
 0.001883
13
SHOW CREATE TABLE `activities`
 0.000284
14
SHOW COLUMNS FROM `users`
 0.001189
15
SHOW CREATE TABLE `users`
 0.000264
16
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
 0.000560
17
INSERT INTO `users` (`role`, `sendEmails`, `sendSms`, `source`, `session`, `lastLogin`, `phone`, `createDate`) VALUES (:yp0, :yp1, :yp2, :yp3, :yp4, :yp5, :yp6, :yp7)
 0.009694
18
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
 0.004435
19
UPDATE `users` SET `lastLogin`=:yp0 WHERE `users`.`id`=2539669
 0.017732
20
SELECT `activities`.`id` AS `t1_c0`, `activities`.`group_id` AS `t1_c1`, `activities`.`resource_id` AS `t1_c2`, `activities`.`title` AS `t1_c3`, `activities`.`type` AS `t1_c4`, `activities`.`facultyNames` AS `t1_c5`, `activities`.`shortDescription` AS `t1_c6`, `activities`.`fullDescription` AS `t1_c7`, `activities`.`creditAmount` AS `t1_c8`, `activities`.`shortAddress` AS `t1_c9`, `activities`.`creditType` AS `t1_c10`, `activities`.`startDate` AS `t1_c11`, `activities`.`finishDate` AS `t1_c12`, `activities`.`sponsors` AS `t1_c13`, `activities`.`status` AS `t1_c14`, `activities`.`createDate` AS `t1_c15`, `activities`.`image` AS `t1_c16`, `activities`.`image_featured` AS `t1_c17`, `activities`.`archived` AS `t1_c18`, `activities`.`managers_list` AS `t1_c19`, `activities`.`is_send_pp_email` AS `t1_c20`, `activities`.`muvi_sync_date` AS `t1_c21`, `activities`.`expert_questions` AS `t1_c22` FROM `activities` `activities` WHERE (`activities`.`resource_id`=:ypl0)
 0.005792
21
SELECT r.id, COUNT(r.id) relevance FROM resources r join `resource_topics` rtj on rtj.`resource_id`=r.id WHERE rtj.`topic_id` in (SELECT topic_id from `resource_topics` rt where rt.`resource_id`=:rid AND rt.topic_id>0) AND r.id <> :rid AND r.status = 'active' Group by r.id order by relevance DESC, r.`createDate` DESC
 0.007767
22
SELECT * FROM `resources` `t` WHERE `t`.`id` IN (143, 132, 129, 122, 109, 89, 81, 73, 51, 50, 49, 48, 45, 42, 38, 33, 30, 29, 20, 18, 16, 14, 13, 9, 11, 4)
 0.005257
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