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A triangle of care: why the liver should not be forgotten

9th November 2021

Dr Kenneth Cusi, chief of the division of endocrinology and diabetes at the University of Florida and Professor Gianluca Perseghin, chief of endocrinology at the University of Milano-Bicocca, team up to discuss why diabetologists should be screening the liver, how best to do it, the lifestyle interventions that can help and medications on the horizon.

In our latest ‘The long and the short of it’, these two leading experts in the field had a reflective and persuasive discussion about the importance of screening the liver when treating patients with type 2 diabetes. If you don’t routinely screen the liver in your clinic, it’s time to start.

In a previous presentation Dr Cusi gave at this year’s World Congress Insulin Resistance, Diabetes and Cardiovascular Disease, he compared non-alcoholic liver disease (NAFLD) and diabetes to a bad marriage – diabetes exacerbates NAFLD, increasing risk of non-alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma, and NAFLD makes diabetes harder to control and insulin resistance worse.

The thrust of this discussion was that it’s being missed in clinics because diabetologists are not looking for it. Both doctors shared their expertise on the best approach for those that want to start doing so.

Dr Cusi pointed out that the American Association for the Study of Liver Disease (AASLD) has said that we should not be screening routinely in its 2018 guidelines, but there’s going to be an update this year and he’s hoping that they’ll follow American Diabetes Association (ADA) guidance and European guidelines, which suggest looking for risk factors. If you have obesity, metabolic syndrome or type 2 diabetes, he says, you should be screened.

How best to do it? The starting point is FIB-4, said Dr Cusi, which is simple and cheap. It’s just your age in a formula with AST, ALT and platelets count, which will go down if you have cirrhosis. If the resulting number is below 1.3, you are probably low risk. Above 2.6 and you’re in trouble. In the middle, where about 30% of people with diabetes sit, more investigation needs to be done. It’s not a perfect test, he said, but it’s helpful, especially in combination with imaging.

Professor Perseghin outlined a study that he and his team carried out after finding that using FIB-4 on type 2 diabetes patients in Milan was frustrating because they found an enormous number of people who needed to be referred to the hepatologist. They sought to improve screening procedures to reduce the number of people being referred.

He also reflected on who should be doing the screening, concluding that it depends on where you work and that diabetologists should work according to their local infrastructure. If you have access to sophisticated screening, use it. If you don’t, work with FIB-4 at the very least.

Dr Cusi added in that the FibroScan is the most widely evaluated imaging technique. A key message, he said, is that we’re not looking for fat, but for fibrosis because that is what will determine the rate of liver complications.

Finally, they addressed a question that often gets asked of them: if we identify a problem, what can we do if we don’t yet have drugs to prevent the progression of liver disease? Dr Cusi pointed out that there are many drugs in development and one may be available late this year. He also discussed lifestyle interventions and bariatric surgery, but maintained that pharmacological intervention has an important role.

Their take-home message was to look at the liver in a way you not have done before – consider its involvement and consider performing some sort of screening in your clinics.

Professor Perseghin is the expert reviewer on our two-module course [] on NAFLD. The first module of this course has recently been accredited by the UK’s Royal College of General Practitioners (RCGP) as an educational resource for continuing professional development and the second module is newly launched, so enrol now to learn more.

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.

Pressed for time? For the short version of Ken and Gianluca’s discussion, click here.

Time to dig deeper? For their full discussion, click here.