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Clinical Prevalence and Treatment Standards for Nonalcoholic Fatty Liver Disease Among Diabetic Patients in India - A Physicians’ Survey


Affiliations
1 Somani Health Clinic, Thane, India
2 Abbott India Ltd., Godrej BKC, Plot No. C– 68, BKC, Near MCA Club, Bandra (E), Mumbai, India
     

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Background/Aims: Type 2 diabetes mellitus (T2DM), obesity, and hyperinsulinemia are predisposing factors for nonalcoholic fatty liver disease (NAFLD). The prevalence of NAFLD in Indian subjects with T2DM is reported to range from 12.5% to 87.5%, with studies over the years showing an increasing trend. This study aimed to understand the prevalence patterns, gaps in management, and current treatment options for the management of NAFLD in Indian patients with T2DM. Methods: A 15-question survey form was used to assess physicians’ practice, and attitudes regarding NAFLD in diabetic patients. Each physician provided data for 15 patients with T2DM and underlying NAFLD who were receiving treatment for NAFLD. Results: In all, 271 physicians from 93 cities responded to the survey. According to 80% of the physicians, NAFLD was prevalent in 40%-60% of patients with T2DM. Diabetes with obesity, hypertension, and dyslipidemia was reported to affect the severity of NAFLD in patients with T2DM. Most patients with T2DM and NAFLD were aged 40-60 years, and 94.5% of physicians responded that their glycated hemoglobin (HbA1c) was >7%. Only 36.5% of the physicians reported screening 40%-60% of patients with T2DM for NAFLD, with liver function tests (LFTs) and ultrasonography being the most common approach used by 78.6% of the physicians. Abnormal LFTs and fatty liver on ultrasonography were the criteria for initiating drug therapy. Lifestyle modifications with drug therapy were the most common approach for management, and ursodeoxycholic acid and vitamin E were the main drugs of choice. Only 33.9% of the physicians used LFTs every three months for follow-up of patients with NAFLD. Conclusion: Although NAFLD was observed in 40%-60% of subjects with T2DM, especially those aged 40-60 years, the percentage of patients screened, treated, and followed-up for NAFLD in routine clinical practice continues to remain low.


Keywords

Type 2 diabetes mellitus, nonalcoholic fatty liver disease, India, prevalence, management
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  • Ludwig J, Viggiano T, McGill D, Ott B. Nonalcoholic steatohepatitis. Mayo Clinic experience with a hitherto unnamed disease. Mayo Clin Proc. 1980;55:434–8.

  • Hazlehurst JM, Woods C, Marjot T, Cobbold JF, Tomlinson JW. Non-alcoholic fatty liver disease and diabetes. Metabolism. 2016;65:1096–108.

  • Farrell GC, Wong VW, Chitturi S. NAFLD in Asia--as common and important as in the West. Nat Rev Gastroenterol Hepatol. 2013;10:307-18.

  • Das K, Das K, Mukherjee PS, Ghosh A, Ghosh S, Mridha AR, et al. Nonobese population in a developing country has a high prevalence of nonalcoholic fatty liver and significant liver disease. Hepatol 2010;51:1593–602.

  • Jun DW, Kim HJ, Bae JH, Lee OY. The clinical significance of HbA1c as a predictive factor for abnormal postprandial glucose metabolism in NAFLD patients with an elevated liver chemistry. Hepatogastroenterol. 2011;58:1274–9.

  • Matsumoto N, Arase Y, Kawamura Y, Ohmoto-Sekine M, Amakawa K, Ogawa K, et al. Significance of oral glucose tolerance tests in non-alcoholic fatty liver disease patients with a fasting plasma glucose level of <126 mg/dL and HbA1c level of ≤ 6.4% in Japan. Intern Med. 2015;54:875–80.

  • Tomah S, Alkhouri N, Hamdy O. Nonalcoholic fatty liver disease and type 2 diabetes: where do Diabetologists stand? Clin Diabetes Endocrinol. 2020;6:9.

  • Anstee QM, McPherson S, Day CP. How big a problem is non-alcoholic fatty liver disease? BMJ. 2011;343:d3897.

  • Bril F, Cusi K. Management of nonalcoholic fatty liver disease in patients with type 2 diabetes: A call to action. Diabetes Care. 2017;40:419–30.

  • Amarapurkar D, Kamani P, Patel N, Gupte P, Kumar P, Agal S, et al. Prevalence of nonalcoholic fatty liver disease: population based study. Ann Hepatol 2007;6:161–3.

  • Gupta M, Mahavar S, Chaturvedi A, Chandra R, Chauhan G, Srivastava S, et al. Magnitude of nonalcoholic fatty liver disease (NAFLD) and concomitant risk factors in patients with type 2 diabetes mellitus. Int J Adv Med. 2017;4:1046–52.

  • Meher LK, Kota SK. Section 7: Gastroenterology, Chapter-66, NAFLD and Diabetes. Medicine Update 2017;2:311.[Cited July 05, 2021] Available from: http://apiindia.org/wp-content/uploads/pdf/medicine_update_2017/mu_066.pdf

  • Targher G, Bertolini L, Rodella S, Tessari R, Zenari L, Lippi G, et al. Nonalcoholic fatty liver disease is independently associated with an increased incidence of cardiovascular events in type 2 diabetic patients. Diab Care. 2007;30:2119–21.

  • Targher G, Lonardo A, Byrne CD. Nonalcoholic fatty liver disease and chronic vascular complications of diabetes mellitus. Nat Rev Endocrinol. 2018;14:99–114.

  • Kalra S, Vithalani M, Gulati G, Kulkarni CM, Kadam Y, Pallivathukkal J, et al. Study of prevalence of nonalcoholic fatty liver disease (NAFLD) in type 2 diabetes patients in India (SPRINT). J Assoc Physicians India. 2013;61:448–53.

  • Leoni S, Tovoli F, Napoli L, Serio I, Ferri S, Bolondi L. Current guidelines for the management of non-alcoholic fatty liver disease: A systematic review with comparative analysis. World J Gastroenterol. 2018;24:3361–37.

  • Dharmalingam M, Yamasandhi PG. Nonalcoholic fatty liver disease and type 2 diabetes mellitus. Indian J Endocrinol Metab. 2018;22:421–8.

  • Prati D, Taioli E, Zanella A, Della Torre E, Butelli S, Del Vecchio E, et al. Updated definitions of healthy ranges for serum alanine aminotransferase levels. Ann Intern Med 2002;137:1–10.

  • American Diabetes Association. 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42:S34– S45.

  • Anstee QM, Targher G, Day CP. Progression of NAFLD to diabetes mellitus, cardiovascular disease or cirrhosis. Nat Rev Gastroenterol Hepatol. 2013;10:330–44.

  • Dasarathy S, Dasarathy J, Khiyami A, Joseph R, Lopez R, McCullough AJ. Validity of real time ultrasound in the diagnosis of hepatic steatosis: a prospective study. J Hepatol. 2009;51:1061–7.

  • European Association for the Study of the Liver (EASL); European Association for the Study of Diabetes (EASD); European Association for the Study of Obesity (EASO). EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. Diabetologia 2016;59:1121–40.

  • Promrat K, Kleiner DE, Niemeier HM, Jackvony E, Kearns M, Wands JR, et al. Randomized controlled trial testing the effects of weight loss on nonalcoholic steatohepatitis. Hepatol. 2010;51:121–9.

  • Duseja A, Das A, Das R, Dhiman RK, Chawla Y, Bhansali A, et al. The clinicopathological profile of Indian patients with nonalcoholic fatty liver disease (NAFLD) is different from that in the West. Dig Dis Sci 2007;52:2368–74.

  • Madan K, Batra Y, Gupta DS, Chander B, Anand Rajan KD, Singh R, et al. Vitamin E-based therapy is effective in ameliorating transaminasemia in nonalcoholic fatty liver disease. Indian J Gastroenterol 2005;24:251–5.

  • Musso G, Gambino R, Cassader M, Pagano G. A meta-analysis of randomized trials for the treatment of nonalcoholic fatty liver disease. Hepatology 2010;52:79–104.

  • Ratziu V, de Ledinghen V, Oberti F, Mathurin P, WartelleBladou C, Renou C, et al. A randomized controlled trial of high-dose ursodesoxycholic acid for nonalcoholic steatohepatitis. J Hepatol 2011;54:1011–9.

  • Adams LA, Angulo P, Petz J, Keach J, Lindor KD. A pilot trial of high-dose ursodeoxycholic acid in nonalcoholic steatohepatitis. Hepatol Int 2010;28;4:628–33.

  • Sanyal AJ, Chalasani N, Kowdley KV, McCullough A, Diehl AM, Bass NM, et al. Pioglitazone, vitamin E, or placebo for nonalcoholic steatohepatitis. N Engl J Med 2010; 362: 1675– 85.

  • Miller ER 3rd, Pastor-Barriuso R, Dalal D, Riemersma RA, Appel LJ, Guallar E. Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Ann Intern Med 2005;142:37–46.

  • Abner EL, Schmitt FA, Mendiondo MS, Marcum JL, Kryscio RJ. Vitamin E and all-cause mortality: a meta-analysis. Curr Aging Sci 2011;4:158–70.

  • National Institute for Health and Care Excellence (UK). NonAlcoholic Fatty Liver Disease: Assessment and Management. NICE guideline [NG49]. [Cited May 27, 2021] Available from: URL: http//www.nice.org.ukguidanceng49.

  • Chalasani N, Younossi Z, Lavine JE, Charlton M, Cusi K, Rinella M, et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatol 2018;67:328–57.

  • European Association for the Study of the Liver (EASL). European Association for the Study of Diabetes (EASD); European Association for the Study of Obesity (EASO). EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol 2016;64:1388–1402.

  • Italian Association for the Study of the Liver (AISF). AISF position paper on nonalcoholic fatty liver disease (NAFLD): Updates and future directions. Dig Liver Dis 2017;49:471–83.

  • Chitturi S, Wong VW, Chan WK, Wong GL, Wong SK, Sollano J, et al. The Asia-Pacific Working Party on Non-alcoholic Fatty Liver Disease guidelines 2017-Part 2: Management and special groups. J Gastroenterol Hepatol 2018;33:86–98.


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  • Clinical Prevalence and Treatment Standards for Nonalcoholic Fatty Liver Disease Among Diabetic Patients in India - A Physicians’ Survey

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Authors

Usha Rathi
Somani Health Clinic, Thane, India
Vinodraj Kundapur
Abbott India Ltd., Godrej BKC, Plot No. C– 68, BKC, Near MCA Club, Bandra (E), Mumbai, India

Abstract


Background/Aims: Type 2 diabetes mellitus (T2DM), obesity, and hyperinsulinemia are predisposing factors for nonalcoholic fatty liver disease (NAFLD). The prevalence of NAFLD in Indian subjects with T2DM is reported to range from 12.5% to 87.5%, with studies over the years showing an increasing trend. This study aimed to understand the prevalence patterns, gaps in management, and current treatment options for the management of NAFLD in Indian patients with T2DM. Methods: A 15-question survey form was used to assess physicians’ practice, and attitudes regarding NAFLD in diabetic patients. Each physician provided data for 15 patients with T2DM and underlying NAFLD who were receiving treatment for NAFLD. Results: In all, 271 physicians from 93 cities responded to the survey. According to 80% of the physicians, NAFLD was prevalent in 40%-60% of patients with T2DM. Diabetes with obesity, hypertension, and dyslipidemia was reported to affect the severity of NAFLD in patients with T2DM. Most patients with T2DM and NAFLD were aged 40-60 years, and 94.5% of physicians responded that their glycated hemoglobin (HbA1c) was >7%. Only 36.5% of the physicians reported screening 40%-60% of patients with T2DM for NAFLD, with liver function tests (LFTs) and ultrasonography being the most common approach used by 78.6% of the physicians. Abnormal LFTs and fatty liver on ultrasonography were the criteria for initiating drug therapy. Lifestyle modifications with drug therapy were the most common approach for management, and ursodeoxycholic acid and vitamin E were the main drugs of choice. Only 33.9% of the physicians used LFTs every three months for follow-up of patients with NAFLD. Conclusion: Although NAFLD was observed in 40%-60% of subjects with T2DM, especially those aged 40-60 years, the percentage of patients screened, treated, and followed-up for NAFLD in routine clinical practice continues to remain low.


Keywords


Type 2 diabetes mellitus, nonalcoholic fatty liver disease, India, prevalence, management

References