S4-E9.3 - Diabetes Drug Choices With Benefits For NAFLD

This week, SurfingNASH is offering conversation segments to showcase our new series, The NASH Tsunami in Diabetes: Getting Ahead of the Rising Tide. Rising Tide, as we call it, is a subscription-only series targeted at the primary care physicians, endocrinologists and allied health professionals who provide front-line treatments for patients living with Type 2 Diabetes and/or obesity. This preview looks at drug choices prescribers can make today for patients with Type 2 Diabetes Mellitus and obesity that have positive impact on Fatty Liver disease. In addition to co-hosts Dr. Ken Cusi and Roger Green, panelists for this discussion include endocrinologist Dr. Scott Isaacs, second author of the recent AACE guidelines, and hepatology researcher Dr. Naim Alkhouri.

Ken notes that we are living in a period where the paradigm around treating chronic metabolic conditions is shifting. In a world where one in five patients with T2DM lives with clinically significant fibrosis, Ken states providers can no longer ignore the liver when making treatment decisions about diabetes. He also suggests that hepatologists need to become more comfortable using medications that were previously reserved for diabetes.

At this point, Naim and Scott join the conversation. Naim begins by discussing EDICT, a trial that compared the standard T2DM regimen of the day (metformin, followed by the sulfonylurea glipizide and then insulin) to a first-line combination therapy of metformin, the GLP-1 agonist exenatide and the PPAR pioglitazone. At the end of this six-year period, the researchers found meaningful, statistically significant differences in three key Fatty Liver parameters: prevalence of NAFLD (69% vs. 31%); clinically significant fibrosis (26% vs. 7%); and percentage fat in the liver (12.5% vs. 8.5%). It also found that patients achieved a lower HbA1c level (6.0% with the combination, vs. 6.8% in the standard treatment group).

In response to a question from Roger, Ken identifies three majors lessons of the last 10 years:

7 of 10 Americans with T2D have a fatty liver; those with NAFLD but not T2D see their chances of becoming diabetic and , separately, developing cardiovascular disease double.

15-20% of Americans with T2D also exhibit moderate-to-advanced cirrhosis.

GLP-1s, as a class, address multiple factors of chronic metabolic disease. They reduced HbA1c, promote and maintain significant weight loss, and slow progression of fibrosis.

Naim expresses a concern that many doctors treating patients with T2D do not consider NASH. A Cleveland Clinic assessment of ICD-10 codes demonstrated that only 5% of T2D patients were coded for NAFLD. This means the 2/3 of the T2D patients in that system have fatty livers and were never evaluated! Similarly, ~2/3 of the patients who present with cirrhosis in his clinic were never told that they had NAFLD. In Naim’s view, NAFLD should be a disease for primary care and endocrinology to treat, while it should be hepatologists that treat NASH.

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The Rising Tide podcast series and all the episodes are produced under a non-restricted grant from Novo Nordisk. Novo Nordisk has neither influenced nor reviewed the contents of this podcast in any way. This content represents the views of the speakers and does not necessarily represent the views of Novo Nordisk. The content herein is for educational purposes only and should not be taken as medical advice.