In this panel, Mary Rinella MD and Lisa VanWagner MD, MSc, FAST, FAHA discuss Nonalcoholic Fatty Liver Disease. They share information on their study in Journal of the Neurological Sciences on the association between NAFLD and stroke and how the association with cardiovascular disease is becoming more appreciated. They talk about the role and limitations of current diagnostics and how important early diagnosis is as being crucial to improve outcome prediction. They also tell us about Northwestern Medicine’s approach to the management of patients with nonalcoholic fatty liver disease and some of the new and exciting research happening in the Northwestern Medicine Non-Alcoholic Fatty Liver Disease Program.
Selected Podcast
Managing Nonalcoholic Fatty Liver Disease
Featured Speakers:
Learn more about Lisa VanWagner, MD
Mary Rinella, MD is a Professor of Medicine in the Division of Gastroenterology and Hepatology at Northwestern Medicine.
Learn more about Mary Rinella, MD
Lisa VanWagner,MD, MSc, FAST, FAHA | Mary Rinella, MD, FACG, FAASLD
Dr. VanWagner is board certified in Internal Medicine, Gastroenterology & Hepatology and Transplant Hepatology and holds active medical licensure in the state of Illinois. She received her medical degree from the University of Virginia School of Medicine in 2007.Learn more about Lisa VanWagner, MD
Mary Rinella, MD is a Professor of Medicine in the Division of Gastroenterology and Hepatology at Northwestern Medicine.
Learn more about Mary Rinella, MD
Transcription:
Managing Nonalcoholic Fatty Liver Disease
Melanie Cole (Host): Welcome. This is Better Edge, a Northwestern Medicine podcast for physicians. I’m Melanie Cole and today, we’re discussing nonalcoholic fatty liver disease. Joining me in this panel are Dr. Mary Rinella, she’s a Professor of Medicine in the Division of Gastroenterology and Hepatology and the Director of the Non-Alcoholic Fatty Liver Disease Program at Northwestern Medicine and Chair of the American Association for the Study of Liver Diseases (AASLD) NASH Task Force, and Dr. Lisa VanWagner. She’s an Assistant Professor of Medicine and Preventive Medicine in the Division of Gastroenterology and Hepatology at Northwestern Medicine. Dr. Rinella, I’d like to start with you. Tell us a little bit about the incidence and burden of nonalcoholic fatty liver disease and what are you seeing in the trends?
Mary Rinella, MD (Guest): So, the prevalence of nonalcoholic fatty liver disease nationally and actually worldwide is approximately 25%. Current estimates are that this burden will increase over time and predicted numbers from 2030, suggest the number will not only increase and people with more advanced disease such as cirrhosis or having complications related to liver disease are predicted to increase by about 168 to 178%. So, what we’ll have is a further increase in burden over time but more importantly, an increase in those with more advanced disease which will burden the healthcare system additively.
Host: Dr. VanWagner, help us to understand the mechanisms that lead to fatty accumulation in the liver in order to develop new treatments. Tell us about nonalcoholic fatty liver disease as it applies to the mechanisms, risk factors or underlying conditions of this disease.
Lisa VanWagner, MD, MSc, FAST, FAHA (Guest): So, that’s a really great question and why don’t I take first the risk factor part of what actually some of the things that we know from an epidemiologic standpoint that are risk factors for fatty liver disease. So, first of all, we know that people who are obese, who have BMIs greater than 30 are at higher risk for the disease. We also know that patients who have underlying metabolic comorbidities like diabetes, dyslipidemia, hypertension, what we would call the metabolic syndrome are all risk factors for incident fatty liver disease and also as Dr. Rinella mentioned, for the more severe forms of NAFLD which we call NASH and also for people who would then develop cirrhosis that those are definite risk factors. Age is also a risk factor and menopause status in women is a risk factor. Postmenopausal women tend to have more severe disease than patients who are premenopausal. So, those are some of the risk factors we know in the general population.
There’s other things that are kind of emerging risk factors that sort of come alongside the disease. We know that patients who have underlying fatty liver disease are more likely to have a history of having other endocrinopathies like PCOS in women. We know that patients with hypothyroidism have a higher prevalence of having fatty liver disease. And also, there’s been associations that there’s increased risk in people who have had prior treatments for certain malignancies and had exposure to certain medications as well are at higher risk of having the disease. So, those are some of the risk factors that we know.
On the other hand of course there’s molecular mechanisms the lead to fat accumulation in the liver and dysregulation of lipid handling and triglyceride handling in the liver which are mechanisms that are linked to actually overload of fat in the liver. And then of course, there is insulin signaling mechanisms as well as problems with other lipid handling in the liver as well.
The other thing and many of those things are exactly what we’re targeting some of the drug mechanisms and I’ll let Dr. Rinella address some of that in the next portion of this. I think one of the most important things to point out is that even though most patients with fatty liver disease do fall into the metabolic syndrome category of risk factors; that there is an entity of fatty liver disease that we call lean NAFLD or lean NASH in which patients are of normal body weight and or don’t have the typical metabolic risk factors and that’s a special population that we are starting to understand more and more and there are specific genetic polymorphisms that have been identified that identify some of that risk both in the metabolic syndrome patients and in the lean NAFLD and NASH patients that definitely place patients at higher risk.
So, it’s a very complex disease with multiple different targets and dysregulation of multiple different things that lead to the systemic process.
Host: Dr. VanWagner, I’d like to stick with you for just a second. You recently published a study in the Journal of the Neurological Sciences on the association between NAFLD and stroke. The association with cardiovascular disease is becoming more appreciated. What can you tell us about stroke risk and what do we know about this association between nonalcoholic fatty liver disease and stroke?
Dr. VanWagner: Yeah, that’s a great question. So, I’ll start by saying that we know that the leading cause of death among all patients who have fatty liver disease is cardiovascular diseases as a composite end point. What we haven’t known much about and the reason why we looked at this in the literature and published this study was how NAFLD specifically might be an additive risk factor for incident stroke. And so, we looked at cumulative data in NHANES, we also looked at this in some of the other stroke cohorts to look at whether or not there was association between markers of fatty liver, whether it was either ultrasound based fatty liver, we’ve looked at elevated liver chemistry tests and association with stroke.
What we find is that there is a small signal for an association with all cause stroke. Interestingly, there was more of an association with hemorrhagic than ischemic stroke which is sort of surprising to us given the mechanisms and so we thought that perhaps there might be something to do with the coagulation cascade and dysregulation in coagulation that might be a risk factor in patients with NAFLD and NASH. And this has been shown in other studies as well. So, what we know is that if somebody has underlying fatty liver disease; that there is some increased risk of patient having stroke, but that a lot of this is probably also mediated by underlying diabetes and underlying obesity. So, most of the association is explained by patients who have underlying diabetes or obesity.
Host: Dr. Rinella, speak about the role and limitations of the current diagnostics and how important is early diagnosis as being crucial to improve outcome prediction.
Dr. Rinella: So, one of the most important unmet needs in the field right now is in diagnostics and biomarkers and that is not so much our ability [00:06:07 cut out] easy to do and reliable but really in our ability to detect those that have steatohepatitis or NASH. We do not have a reliable biomarker to do that right now. We have improvements in emerging biomarkers that detect advanced fibrosis and advanced liver disease and those I think are to the point where they are useful to at least exclude patients who do not have advanced disease.
The most commonly used method to do that is FibroScan with transient elastography. It’s available in many offices and is able risk stratify with a fair amount of confidence. The negative predictive value of that test is quite good about 97% or so for exclusion of advanced fibrosis. And the positive predictive value is not as good about 70% but again, allows us to minimize liver biopsy as far as outcome prediction.
We do have the ability to predict outcomes to some extent using just clinical prediction rules such as the NAFLD Fibrosis Score or FIB-4. Other biomarkers that will be available fairly soon such as the ELF test which is a combination test of multiple [00:07:17 cut off] That has the ability to predict outcomes over time liver related and [00:07:22 cut off] So, we look forward to that being approved by the FDA shortly.
Host: And Dr. VanWagner, tell us about Northwestern Medicine’s approach to the management of patients with nonalcoholic fatty liver disease. What’s unique about what you are doing? Speak about your multidisciplinary approach, your team and help us to understand how fatty liver impacts the care of every patient with obesity, type 2 diabetes, and cardiovascular disease.
Dr. VanWagner: So, Dr. Rinella and myself and the team here at Northwestern have spent a lot of time developing the Northwestern Fatty Liver Clinic. And I think what’s really unique about the clinic here and that providers should know when they refer a patient to us is that we have a comprehensive clinic where we are collocated Dr. Rinella and myself as in clinic together. We work with the same nurses and we also have an onsite dietician who sees all of our patients as part of the comprehensive visit. And so, they are not only getting both the medical evaluation so that we can as Dr. Rinella said, risk stratify their disease to sort of detect who has just NAFLD and who might have more advanced fibrosis and potentially be at further risk of cirrhosis, but then we can also offer comprehensive dietary and lifestyle counseling as part of that initial visit.
That dietician also is able to see patients in follow up and then we are housed within the Lifestyle Medicine Clinic at Northwestern and so, if we detect that patients might need further aggressive lifestyle interventions or lifestyle therapies in addition to just dietary counseling; we can also offer adjuvant medications for helping with weightloss and also refer appropriate patients for bariatric surgery evaluations which is a highly effective therapy for fatty liver. We have all of those abilities within the comprehensive clinic.
Things that I think also make the clinic very unique is that Dr. Rinella is the site principle investigator for numerous clinical trials that are being conducted nationally and internationally in the NAFLD and NASH sphere and I’m also a coinvestigator with her and participate in those trials as well. And so, all patients that come into our Fatty Liver Clinic are also evaluated for clinical trial eligibility because as of today, March 13, 2020, we still do not have an FDA approved medication though there are many in the pipeline and hopefully one that will be approved by the end of this calendar year. So, we are very hopeful that we will be able to offer new therapies in addition to what’s available in clinical trials within our comprehensive clinic.
So, I think those are some of the main things that make the clinic very unique and allow us to offer comprehensive care for this patient population. To address you other question is how does the impact of having fatty liver impact on the care of just patients in general. One of the things that we are looking at as a fatty liver team and a research team here at Northwestern is what is the impact of actually identifying fat on imaging or incidentally which is actually how most people with this disease are actually detected. Most patients actually, with NAFLD and more severe disease NASH, do not actually have abnormal liver chemistries or liver tests. And so they often go undiagnosed for a long period of time. And are often just picked up when they are having an image done for other reasons.
So, they come in to their primary care doctor with abdominal pain and somebody orders an ultrasound and they are noted to have fatty liver on an ultrasound, or they come into the emergency room for another complaint and they get a CAT scan and they are noted to have fat in their liver. So, we’re trying to better understand how to best evaluate those patients, risk stratify them using some of the noninvasive tools that Dr. Rinella talked about like the FIB-4 and the NAFLD Fibrosis Score. How can we better identify these patients and get them linked to hepatology care, get them linked to the Fatty Liver Clinic so that we can help actually treat the disease, identify those high risk patients and manage them in comprehensive clinic alongside endocrinology and cardiology and all the other important players that come into managing the systemic disease.
Host: Well thank you for that very comprehensive answer and Dr. Rinella, tell us about some of the new and exciting research that’s happening. Dr. VanWagner touched on it a little bit. But tell us about the Northwestern Medicine Nonalcoholic Fatty Liver Disease Program and what are some current advances that we should know about?
Dr. Rinella: Well as far as advances in new therapeutics, there should be approval by the FDA of our first agent for NASH this summer. So, that will change our approach slightly, I think. It’s a drug that will be tolerated by some but not all patients. I think it will change somewhat the way we approach our patients. As Lisa mentioned, we try to provide a very comprehensive approach including the use of off label medications such as weightloss drugs and antidiabetic drugs that should by a mechanism of action have benefit. So, as far as emerging therapeutics that are interesting, you can classify them basically as anti-lipid medications, antimetabolic medications and then anti-inflammatory or fibroinflammatory medication interventions. Of those we have four phase three trials that are ongoing.
The closest to FDA approval after the one that’s about to be approved which will be a beta cholic acid would be combined PPAR alpha delta agonist which reduces lipids in the liver, reduces triglycerides peripherally and improves inflammatory signaling. And then the other agent that I think is a mechanism that I think is very promising is thyroid hormone receptor beta agonist. As Lisa or Dr. VanWagner mentioned, there is subclinical hypothyroidism in a fair amount of people with fatty liver disease and these particular agents target the beta receptor of the thyroid hormone which results in very favorable lipid changes in the liver and a reduction in inflammatory markers. But there are several drugs. I think we have nine actively enrolling trials right now.
Host: And Dr. VanWagner, as we wrap up, is there anything else you’d like providers to know and take forward to help their patients and when you feel it’s important that they refer to the specialists at Northwestern Medicine.
Dr. VanWagner: Yeah, I think the most important thing is the shared knowledge of the fact that we are here to help providers to understand the disease and to help them triage. If a provider ever has a question about whether a patient should be seen by hepatology; Dr. Rinella and I are always available as are our other hepatologists to answer any questions that anyone might have. Feel free to contact us via email or MyChart or page us through the system and we’re happy to have conversations about patients.
I think in general, some of the things that we mentioned, the patients that we already know that are definitely high risk which are of course those with metabolic comorbidities, type 2 diabetics, patients who have any family history of fatty liver disease or family history of liver disease in general or cirrhosis are absolutely people that need to be referred. Of course, we see a lot of people that have elevated liver chemistries that are referred to us and that’s definitely a marker, but I don’t want to say that people should not be reassured when somebody has normal liver chemistries. That is not a reason to not refer to hepatology. We are happy to see those patients.
As Dr. Rinella mentioned, I think some of the helpful online tools that can help a provider understand somebody’s risk is to actually calculate a FIB-4 or a NAFLD Fibrosis Score. Both of those are available as free online calculators or through online apps in the App Store through MedCalc and other things. and you can see your patient’s risk might be. If anyone is an indeterminant risk or higher, they should be referred for sure to a hepatologist. But again, we’re available to you and we are always happy to see patients and have conversations about their risk.
Host: Thank you Doctors so much for joining us and sharing your expertise with the listeners today. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at www.nm.org to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. For more health tips and updates, follow us on your social channels. I’m Melanie Cole.
Managing Nonalcoholic Fatty Liver Disease
Melanie Cole (Host): Welcome. This is Better Edge, a Northwestern Medicine podcast for physicians. I’m Melanie Cole and today, we’re discussing nonalcoholic fatty liver disease. Joining me in this panel are Dr. Mary Rinella, she’s a Professor of Medicine in the Division of Gastroenterology and Hepatology and the Director of the Non-Alcoholic Fatty Liver Disease Program at Northwestern Medicine and Chair of the American Association for the Study of Liver Diseases (AASLD) NASH Task Force, and Dr. Lisa VanWagner. She’s an Assistant Professor of Medicine and Preventive Medicine in the Division of Gastroenterology and Hepatology at Northwestern Medicine. Dr. Rinella, I’d like to start with you. Tell us a little bit about the incidence and burden of nonalcoholic fatty liver disease and what are you seeing in the trends?
Mary Rinella, MD (Guest): So, the prevalence of nonalcoholic fatty liver disease nationally and actually worldwide is approximately 25%. Current estimates are that this burden will increase over time and predicted numbers from 2030, suggest the number will not only increase and people with more advanced disease such as cirrhosis or having complications related to liver disease are predicted to increase by about 168 to 178%. So, what we’ll have is a further increase in burden over time but more importantly, an increase in those with more advanced disease which will burden the healthcare system additively.
Host: Dr. VanWagner, help us to understand the mechanisms that lead to fatty accumulation in the liver in order to develop new treatments. Tell us about nonalcoholic fatty liver disease as it applies to the mechanisms, risk factors or underlying conditions of this disease.
Lisa VanWagner, MD, MSc, FAST, FAHA (Guest): So, that’s a really great question and why don’t I take first the risk factor part of what actually some of the things that we know from an epidemiologic standpoint that are risk factors for fatty liver disease. So, first of all, we know that people who are obese, who have BMIs greater than 30 are at higher risk for the disease. We also know that patients who have underlying metabolic comorbidities like diabetes, dyslipidemia, hypertension, what we would call the metabolic syndrome are all risk factors for incident fatty liver disease and also as Dr. Rinella mentioned, for the more severe forms of NAFLD which we call NASH and also for people who would then develop cirrhosis that those are definite risk factors. Age is also a risk factor and menopause status in women is a risk factor. Postmenopausal women tend to have more severe disease than patients who are premenopausal. So, those are some of the risk factors we know in the general population.
There’s other things that are kind of emerging risk factors that sort of come alongside the disease. We know that patients who have underlying fatty liver disease are more likely to have a history of having other endocrinopathies like PCOS in women. We know that patients with hypothyroidism have a higher prevalence of having fatty liver disease. And also, there’s been associations that there’s increased risk in people who have had prior treatments for certain malignancies and had exposure to certain medications as well are at higher risk of having the disease. So, those are some of the risk factors that we know.
On the other hand of course there’s molecular mechanisms the lead to fat accumulation in the liver and dysregulation of lipid handling and triglyceride handling in the liver which are mechanisms that are linked to actually overload of fat in the liver. And then of course, there is insulin signaling mechanisms as well as problems with other lipid handling in the liver as well.
The other thing and many of those things are exactly what we’re targeting some of the drug mechanisms and I’ll let Dr. Rinella address some of that in the next portion of this. I think one of the most important things to point out is that even though most patients with fatty liver disease do fall into the metabolic syndrome category of risk factors; that there is an entity of fatty liver disease that we call lean NAFLD or lean NASH in which patients are of normal body weight and or don’t have the typical metabolic risk factors and that’s a special population that we are starting to understand more and more and there are specific genetic polymorphisms that have been identified that identify some of that risk both in the metabolic syndrome patients and in the lean NAFLD and NASH patients that definitely place patients at higher risk.
So, it’s a very complex disease with multiple different targets and dysregulation of multiple different things that lead to the systemic process.
Host: Dr. VanWagner, I’d like to stick with you for just a second. You recently published a study in the Journal of the Neurological Sciences on the association between NAFLD and stroke. The association with cardiovascular disease is becoming more appreciated. What can you tell us about stroke risk and what do we know about this association between nonalcoholic fatty liver disease and stroke?
Dr. VanWagner: Yeah, that’s a great question. So, I’ll start by saying that we know that the leading cause of death among all patients who have fatty liver disease is cardiovascular diseases as a composite end point. What we haven’t known much about and the reason why we looked at this in the literature and published this study was how NAFLD specifically might be an additive risk factor for incident stroke. And so, we looked at cumulative data in NHANES, we also looked at this in some of the other stroke cohorts to look at whether or not there was association between markers of fatty liver, whether it was either ultrasound based fatty liver, we’ve looked at elevated liver chemistry tests and association with stroke.
What we find is that there is a small signal for an association with all cause stroke. Interestingly, there was more of an association with hemorrhagic than ischemic stroke which is sort of surprising to us given the mechanisms and so we thought that perhaps there might be something to do with the coagulation cascade and dysregulation in coagulation that might be a risk factor in patients with NAFLD and NASH. And this has been shown in other studies as well. So, what we know is that if somebody has underlying fatty liver disease; that there is some increased risk of patient having stroke, but that a lot of this is probably also mediated by underlying diabetes and underlying obesity. So, most of the association is explained by patients who have underlying diabetes or obesity.
Host: Dr. Rinella, speak about the role and limitations of the current diagnostics and how important is early diagnosis as being crucial to improve outcome prediction.
Dr. Rinella: So, one of the most important unmet needs in the field right now is in diagnostics and biomarkers and that is not so much our ability [00:06:07 cut out] easy to do and reliable but really in our ability to detect those that have steatohepatitis or NASH. We do not have a reliable biomarker to do that right now. We have improvements in emerging biomarkers that detect advanced fibrosis and advanced liver disease and those I think are to the point where they are useful to at least exclude patients who do not have advanced disease.
The most commonly used method to do that is FibroScan with transient elastography. It’s available in many offices and is able risk stratify with a fair amount of confidence. The negative predictive value of that test is quite good about 97% or so for exclusion of advanced fibrosis. And the positive predictive value is not as good about 70% but again, allows us to minimize liver biopsy as far as outcome prediction.
We do have the ability to predict outcomes to some extent using just clinical prediction rules such as the NAFLD Fibrosis Score or FIB-4. Other biomarkers that will be available fairly soon such as the ELF test which is a combination test of multiple [00:07:17 cut off] That has the ability to predict outcomes over time liver related and [00:07:22 cut off] So, we look forward to that being approved by the FDA shortly.
Host: And Dr. VanWagner, tell us about Northwestern Medicine’s approach to the management of patients with nonalcoholic fatty liver disease. What’s unique about what you are doing? Speak about your multidisciplinary approach, your team and help us to understand how fatty liver impacts the care of every patient with obesity, type 2 diabetes, and cardiovascular disease.
Dr. VanWagner: So, Dr. Rinella and myself and the team here at Northwestern have spent a lot of time developing the Northwestern Fatty Liver Clinic. And I think what’s really unique about the clinic here and that providers should know when they refer a patient to us is that we have a comprehensive clinic where we are collocated Dr. Rinella and myself as in clinic together. We work with the same nurses and we also have an onsite dietician who sees all of our patients as part of the comprehensive visit. And so, they are not only getting both the medical evaluation so that we can as Dr. Rinella said, risk stratify their disease to sort of detect who has just NAFLD and who might have more advanced fibrosis and potentially be at further risk of cirrhosis, but then we can also offer comprehensive dietary and lifestyle counseling as part of that initial visit.
That dietician also is able to see patients in follow up and then we are housed within the Lifestyle Medicine Clinic at Northwestern and so, if we detect that patients might need further aggressive lifestyle interventions or lifestyle therapies in addition to just dietary counseling; we can also offer adjuvant medications for helping with weightloss and also refer appropriate patients for bariatric surgery evaluations which is a highly effective therapy for fatty liver. We have all of those abilities within the comprehensive clinic.
Things that I think also make the clinic very unique is that Dr. Rinella is the site principle investigator for numerous clinical trials that are being conducted nationally and internationally in the NAFLD and NASH sphere and I’m also a coinvestigator with her and participate in those trials as well. And so, all patients that come into our Fatty Liver Clinic are also evaluated for clinical trial eligibility because as of today, March 13, 2020, we still do not have an FDA approved medication though there are many in the pipeline and hopefully one that will be approved by the end of this calendar year. So, we are very hopeful that we will be able to offer new therapies in addition to what’s available in clinical trials within our comprehensive clinic.
So, I think those are some of the main things that make the clinic very unique and allow us to offer comprehensive care for this patient population. To address you other question is how does the impact of having fatty liver impact on the care of just patients in general. One of the things that we are looking at as a fatty liver team and a research team here at Northwestern is what is the impact of actually identifying fat on imaging or incidentally which is actually how most people with this disease are actually detected. Most patients actually, with NAFLD and more severe disease NASH, do not actually have abnormal liver chemistries or liver tests. And so they often go undiagnosed for a long period of time. And are often just picked up when they are having an image done for other reasons.
So, they come in to their primary care doctor with abdominal pain and somebody orders an ultrasound and they are noted to have fatty liver on an ultrasound, or they come into the emergency room for another complaint and they get a CAT scan and they are noted to have fat in their liver. So, we’re trying to better understand how to best evaluate those patients, risk stratify them using some of the noninvasive tools that Dr. Rinella talked about like the FIB-4 and the NAFLD Fibrosis Score. How can we better identify these patients and get them linked to hepatology care, get them linked to the Fatty Liver Clinic so that we can help actually treat the disease, identify those high risk patients and manage them in comprehensive clinic alongside endocrinology and cardiology and all the other important players that come into managing the systemic disease.
Host: Well thank you for that very comprehensive answer and Dr. Rinella, tell us about some of the new and exciting research that’s happening. Dr. VanWagner touched on it a little bit. But tell us about the Northwestern Medicine Nonalcoholic Fatty Liver Disease Program and what are some current advances that we should know about?
Dr. Rinella: Well as far as advances in new therapeutics, there should be approval by the FDA of our first agent for NASH this summer. So, that will change our approach slightly, I think. It’s a drug that will be tolerated by some but not all patients. I think it will change somewhat the way we approach our patients. As Lisa mentioned, we try to provide a very comprehensive approach including the use of off label medications such as weightloss drugs and antidiabetic drugs that should by a mechanism of action have benefit. So, as far as emerging therapeutics that are interesting, you can classify them basically as anti-lipid medications, antimetabolic medications and then anti-inflammatory or fibroinflammatory medication interventions. Of those we have four phase three trials that are ongoing.
The closest to FDA approval after the one that’s about to be approved which will be a beta cholic acid would be combined PPAR alpha delta agonist which reduces lipids in the liver, reduces triglycerides peripherally and improves inflammatory signaling. And then the other agent that I think is a mechanism that I think is very promising is thyroid hormone receptor beta agonist. As Lisa or Dr. VanWagner mentioned, there is subclinical hypothyroidism in a fair amount of people with fatty liver disease and these particular agents target the beta receptor of the thyroid hormone which results in very favorable lipid changes in the liver and a reduction in inflammatory markers. But there are several drugs. I think we have nine actively enrolling trials right now.
Host: And Dr. VanWagner, as we wrap up, is there anything else you’d like providers to know and take forward to help their patients and when you feel it’s important that they refer to the specialists at Northwestern Medicine.
Dr. VanWagner: Yeah, I think the most important thing is the shared knowledge of the fact that we are here to help providers to understand the disease and to help them triage. If a provider ever has a question about whether a patient should be seen by hepatology; Dr. Rinella and I are always available as are our other hepatologists to answer any questions that anyone might have. Feel free to contact us via email or MyChart or page us through the system and we’re happy to have conversations about patients.
I think in general, some of the things that we mentioned, the patients that we already know that are definitely high risk which are of course those with metabolic comorbidities, type 2 diabetics, patients who have any family history of fatty liver disease or family history of liver disease in general or cirrhosis are absolutely people that need to be referred. Of course, we see a lot of people that have elevated liver chemistries that are referred to us and that’s definitely a marker, but I don’t want to say that people should not be reassured when somebody has normal liver chemistries. That is not a reason to not refer to hepatology. We are happy to see those patients.
As Dr. Rinella mentioned, I think some of the helpful online tools that can help a provider understand somebody’s risk is to actually calculate a FIB-4 or a NAFLD Fibrosis Score. Both of those are available as free online calculators or through online apps in the App Store through MedCalc and other things. and you can see your patient’s risk might be. If anyone is an indeterminant risk or higher, they should be referred for sure to a hepatologist. But again, we’re available to you and we are always happy to see patients and have conversations about their risk.
Host: Thank you Doctors so much for joining us and sharing your expertise with the listeners today. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at www.nm.org to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. For more health tips and updates, follow us on your social channels. I’m Melanie Cole.