NASH treatment

Current recommended treatment options for non-alcoholic steatohepatitis (NASH) focus primarily on lifestyle modifications and selective pharmacological therapies in secondary or tertiary care settings.

• Lifestyle modification: All patients should be advised on diet, physical activity, and gradual sustained weight loss, especially if overweight or obese, targeting 5-10% weight loss over 6 months with a calorie deficit of approximately 600 kcal/day. Aerobic exercise combined with diet is the most effective approach to reduce liver fat and improve insulin sensitivity. A Mediterranean diet is recommended, and alcohol intake should be kept within national recommended limits ¹,².
• Pharmacological treatment: There is currently no licensed drug treatment for NASH in primary care. However, in secondary or tertiary care, off-label use of pioglitazone or vitamin E may be considered for adults with advanced liver fibrosis, regardless of diabetes status. Pioglitazone requires caution due to risks including weight gain, bladder cancer, osteoporosis, and contraindications such as heart failure and bladder cancer history. Vitamin E is also considered in children and young people with advanced fibrosis in tertiary care ¹,².
• Other treatments: Obeticholic acid, a synthetic analogue of chenodeoxycholic acid, has evidence of improving histological features of NASH including fibrosis and may be used in specialist settings ¹.
• Bariatric surgery: For eligible patients, bariatric surgery can result in biopsy-confirmed resolution of steatosis in about 66% and fibrosis in 40% of patients, and is considered in specialist care ¹.
• Monitoring and referral: Patients with suspected or confirmed NASH and advanced fibrosis should be referred to hepatology specialists for further assessment and management, including possible liver biopsy and surveillance for complications ¹,².