Fatty Liver (Steatosis Hepatis): Drug Therapy

Therapeutic targets

  • Reduction of insulin resistance (decreased or abolished action of the hormone insulin) with decreased cardiovascular end-organ damage.
  • Prevention of progression (progression) to nonalcoholic steatohepatitis (NASH) and/or hepatocellular carcinoma (HCC).
  • In proven NASH, to prevent progressive fibrosis with development of cirrhosis (irreversible (non-reversible) damage to the liver and marked remodeling of liver tissue) and its complications.

Therapy recommendations

  • Unfortunately, there is currently no reliable drug therapy proven in studies that can be used for fatty liver disease. However, the positive effect of a healthy diet, weight reduction, abstaining from alcohol and increasing exercise is undisputed.
  • In steatosis hepatis, the underlying diseases and metabolic risk factors are primarily treated.
  • The following drugs/micronutrients can be used adjuvantly:
  • Pioglitazone (insulin sensitizer): leads to improvement of even late stages of fibrosis in non-alcoholic steatohepatitis (NASH); see below Further notes.
  • Furthermore, measures should be taken to achieve risk-adjusted target values for arterial blood pressure, HbA1c, and LDL cholesterol. (strong consensus) (strong recommendation)
  • See also under “Further Therapy.”

* Cannot be recommended based on current data. (strong consensus) (open recommendation).

Lipid-lowering agents

Lipid-lowering agents (lipid-lowering drugs) are used to treat dyslipidemia (lipid metabolism disorders). They lower various subunits of lipids in the blood, depending on the drug class:

Compound Strongest reduction with
Statins (cholesterol synthesis inhibitors) LDL cholesterol, triglycerides
Fibrates Triglycerides
Exchange resins LDL cholesterol
Nicotinic acid Triglycerides
Omega-3 fatty acids (DHA; EPA) Triglycerides

Ursodeoxycholic acid

Ursodeoxycholic acid is a bile acid that is also used as a drug in the therapy of gallstones and in cystic fibrosis. It is thought to have a protective effect on hepatocytes (liver cells) and increase bile acid turnover. Studies are still ongoing for the therapy of steatosis hepatis, but they already suggest a positive effect.

Betaine

Betaine is a precursor of S-adenosyl methionine, an important metabolic product. It is used in many different diseases, and studies are showing initial positive indications in the therapy of steatosis hepatis (fatty liver).

Antioxidants

Antioxidants such as vitamin E or N-acetylcysteine are also thought to protect hepatocytes (liver cells). Further notes

  • Metabolically neutral antihypertensives should be preferred in cases of hypertension (high blood pressure) requiring treatment-primarily inhibitors of the renin-angiotensin-aldosterone system. (strong consensus) (recommendation)
  • Vasodilating drugs should not be used in decompensated cirrhosis. (strong consensus) (strong recommendation)
  • In manifest type 2 diabetes, up to stage Child A, metformin can be used as the 1st-choice oral antidiabetic drug even in the presence of elevated transaminases. (strong consensus) (open recommendation).
  • When anticoagulation (anticoagulation) with phenprocoumon or direct oral anticoagulants is used, restrictions on use in the presence of elevated liver enzymes or contraindications in hepatic insufficiency with coagulopathy should be considered. (strong consensus) (recommendation)
  • Patients with nonalcoholic fatty liver (NAFLD) who lose weight by dietary or bariatric surgical measures should take concomitant ursodeoxycholic acid (UDCS) to prevent cholelithiasis (gallstones) and its complications. (Consensus) (Recommendation)
  • The indication for antiviral therapy should be given in HIV infection regardless of the presence of concomitant NAFLD. (strong consensus) (strong recommendation)
  • The insulin sensitizer pioglitazone (30-45 mg) can improve even late-stage fibrosis in nonalcoholic steatohepatitis (NASH). This is also true for non-diabetics. Glitazone therapy increased the probability by 3.4-fold a stage F3 or 4 fibrosis (bridging fibrosis or cirrhosis) back to a stage F2 or below (patients without diabetes mellitus: 2.95-fold; NASH cure: 3.4-fold); NNT ((Number Needed to Treat) of 1.9, i.e. only two NASH patients would need to be treated with pioglitazone to improve advanced hepatic fibrosis.Treatment duration: 18 months.

Supplements (dietary supplements; vital substances)

Suitable dietary supplements should contain the following vital substances:

Note: The listed vital substances are not a substitute for drug therapy. Food supplements are intended to supplement the general diet in the particular life situation.