Type 2 diabetes

NAFLD pathway should be integrated into T2D care cycle

Nonalcoholic fatty liver disease (NAFLD) is overlooked as a diabetes complication and should be incorporated into the routine cycle of care, Australian researchers have suggested.

Despite being highly prevalent in people with T2D there are major gaps in NAFLD assessment, diagnosis and management in Australia that could be remedied with a specific NAFLD pathway, results from Queensland study have shown.

Researchers from the Centre for Liver Disease Research at the University of Queensland found that the implementation of a NAFLD pathway in routine care was being hampered by many factors including lack of concern among clinicians about liver-related consequences of T2D, uncertainty about management and limited access to resources such as fibrosis tests.

In focus groups conducted with seven endocrinologists and nine GPs, responses from participants suggested that NAFLD was not considered a priority in patients with T2D  because clinicians thought the long-term consequences such as liver cancer were uncommon and its diagnosis would not alter current management.

However most participants acknowledged that NAFLD was common and said they would like to see structured guidance on the assessment and management of the condition.

A NAFLD pathway could include a risk assessment tool and clear criteria that identify patients who require further investigation, they said. GPs said they would like explanations for interpretation of liver function tests and what must be actioned, including appropriate patient management and follow up with tests for fibrosis.

Both endocrinologists and GPs agreed that any NAFLD pathway would have to be integrated into routine diabetes management in primary care.

“I would say it’s not rocket science … Like anything, it would just be an algorithm we would put into our review, our care plan reviews, that we need to be doing this at this point. So I think most GPs who do chronic disease would be comfortable,” said one participant.

“Every 3 months we are doing a review of their HbA1c, checking renal function, and just running past have they had their urine albumin check—all those tick box things … At the moment I don’t think there is a liver part to that, so that could be added to a typical diabetes clinic disease review that is done at practices,” said another.

Endocrinologists said much of the management of NAFLD would overlap with current dietary and drug approaches to T2D, but there was still a need to integrate this into practice to make patients aware of the condition.

“Diabetes has changed a lot in the last 10 years with the advent of newer agents which prevent other comorbid conditions, like the SGLT−2 and GLP−1 [agents]. So diabetes isn’t about numbers and A1Cs anymore, it’s about prevention of other things. You don’t die from diabetes you die from heart attacks and cirrhosis … So I think there’s good space for it [management of NAFLD],” said one.

“Armed with a risk stratification tool [and] access to a scan – I think that would change the shape of the conversation we would have with people about their liver disease,” said another.

“We all try to improve their glycaemic control, their metabolic profile, but often it gets a bit lumped into one conversation. But if we’re got something saying that this patient is at really high risk for having advanced fibrosis, the shape of that conversation might change and you might … actually have more of a breakthrough,” said another.

The researchers said the focus group discussions had highlighted the “gap in clinical practice for the implementation of clear, evidence-based guidelines for NAFLD in people with diabetes.”

“By focusing on comorbidity prevention and integrating NAFLD as a diabetes complication to be addressed during established cycles of care, many barriers to implementing a NAFLD pathway in primary care could be overcome,” they suggested.

The findings are published in Diabetic Medicine.

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