Non-alcoholic fatty liver disease (NAFLD): assessment and management

National Institute for Health and Care Excellence


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Assessment for NAFLD

Identifying NAFLD in higher-risk groups

  • Be aware that non-alcoholic fatty liver disease (NAFLD) is more common in people who have:
    • type 2 diabetes or
    • metabolic syndrome
  • Take an alcohol history to rule out alcohol-related liver disease. See also NICE's cirrhosis guideline
  • Do not use routine liver blood tests to rule out NAFLD

Diagnosing NAFLD in children and young people

  • Offer a liver ultrasound to test children and young people for NAFLD if they:
    • have type 2 diabetes or metabolic syndrome and
    • do not misuse alcohol
  • Refer children with suspected NAFLD to a relevant paediatric specialist in hepatology in tertiary care
  • Diagnose children and young people with NAFLD if:
    • ultrasound shows they have fatty liver and
    • other suspected causes of fatty liver have been ruled out
  • Offer liver ultrasound to retest children and young people for NAFLD every 3 years if they:
    • have a normal ultrasound and
    • have type 2 diabetes or metabolic syndrome and
    • do not misuse alcohol

Assessment and monitoring of NAFLD in adults, children, and young people

algorithm-for-the-assessment-and-monitoring-of-NAFLD-in-adults-children-and-young-people

Assessment for advanced liver fibrosis in people with NAFLD

Identifying people with advanced liver fibrosis 

  • Offer testing for advanced liver fibrosis to people with NAFLD
  • Consider using the enhanced liver fibrosis (ELF) test in people who have been diagnosed with NAFLD to test for advanced liver fibrosis
  • Do not use routine liver blood tests to assess for advanced liver fibrosis in people with NAFLD
  • Diagnose people with advanced liver fibrosis if they have:
    • an ELF score of 10.51 or above and
    • NAFLD
  • Refer adults and young people diagnosed with advanced liver fibrosis to a relevant specialist in hepatology
  • Explain to people with an ELF score below 10.51 that:
    • they are unlikely to have advanced liver fibrosis and
    • reassessment for advanced liver fibrosis every 3 years for adults and every 2 years for children and young people is sufficient for regular monitoring and
    • no interim tests are needed
  • Give the person advice about lifestyle modifications they may be able to make
  • Offer retesting for advanced liver fibrosis for people with an ELF score below 10.51:
    • every 3 years to adults
    • every 2 years to children and young people
  • Consider using ELF for retesting people with advanced liver fibrosis

Monitoring adults and young people over 16 for cirrhosis

  • Monitor adults and young people over 16 with NAFLD and advanced liver fibrosis for cirrhosis in line with NICE's cirrhosis guideline

Extra-hepatic conditions

  • Be aware that NAFLD is a risk factor for type 2 diabetes, hypertension and chronic kidney disease
  • Be aware that in people with type 2 diabetes, NAFLD is a risk factor for atrial fibrillation, myocardial infarction, ischaemic stroke and death from cardiovascular causes

Lifestyle modifications for NAFLD

  • Offer advice on physical activity and diet to people with NAFLD who are overweight or obese in line with NICE's obesity and preventing excess weight gain guidelines
  • Explain to people with NAFLD that there is some evidence that exercise reduces liver fat content
  • Consider the lifestyle interventions in NICE's obesity guideline for people with NAFLD regardless of their BMI
  • Do not offer omega-3 fatty acids to adults with NAFLD because there is not enough evidence to recommend their use
  • Explain to people with NAFLD who drink alcohol the importance of staying within the national recommended limits for alcohol consumption

People with NAFLD who are taking statins

  • Be aware that people with NAFLD who are taking statins should keep taking them
  • Only consider stopping statins if liver enzyme levels double within 3 months of starting statins, including in people with abnormal baseline liver blood results

Pharmacological treatment

  • In secondary or tertiary care settings only, consider pioglitazone* or vitamin E for adults with advanced liver fibrosis, whether they have diabetes or not
  • Before prescribing pioglitazone or vitamin E to adults, take into account any comorbidities that they have and the risk of adverse events associated with these conditions
  • In tertiary care settings only, consider vitamin E for children with advanced liver fibrosis, whether they have diabetes or not
  • In secondary or tertiary care settings only, consider vitamin E for young people with advanced liver fibrosis, whether they have diabetes or not
  • Offer to retest people with advanced liver fibrosis 2 years after they start a new pharmacological therapy to assess whether treatment is effective
  • Consider using the ELF test to assess whether pharmacological therapy is effective
  • If an adult's ELF test score has risen, stop either vitamin E or pioglitazone and consider switching to the other pharmacological therapy
  • If a child or young person's ELF test score has risen, stop vitamin E

Terms used in this guideline

Advanced liver fibrosis

  • A grade of F3 or above using the Kleiner (NASH-CRN) or the steatosis, activity and fibrosis (SAF) score. This is referred to as bridging fibrosis (the presence of fibrosis linking hepatic veins to portal tracts

Adults, children and young people

  • These are defined as:
    • children: over 1 year to under 16 years
    • young people: 16 to under 18
    • adults: 18 or older

Metabolic syndrome

  • A group of chronic conditions that indicates increased cardiovascular risk. It includes central obesity (excessive abdominal fat), insulin resistance or type 2 diabetes, hypertension and dyslipidaemia

*When prescribing pioglitazone, exercise particular caution if the person is at high risk of the adverse effects of the drug. Pioglitazone is contraindicated in people with a history of heart failure, previous or active bladder cancer and uninvestigated macroscopic haematuria (visible red blood cells in the urine). Known risk factors for these conditions, including increased age, should be carefully evaluated before treatment: see the manufacturers' summaries of product characteristics for details

At the time of publication (July 2016), neither pioglitazone nor vitamin E had a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines—guidance for doctors for further information

References

full guidelines available from...
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/NG49

National Institute for Health and Care Excellence. Non-alcoholic fatty liver disease (NAFLD): assessment and management. July 2016.



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