The prevalence of non-alcoholic fatty liver disease (NAFLD) has increased and easier, non-invasive ways of assessing the disease have become available in recent years but there is still a concerning under-recognition of the disease.

A survey that asked Queensland GPs about their awareness and understanding of NAFLD has revealed a number of knowledge and practice gaps, according to liver specialist Professor Elizabeth Powell.

Doctors typically underestimated how common the disease was, were unsure about contemporary methods of assessing the disease, and were under-referring patients for specialist review.

Professor Powell, from the Centre for Liver Disease Research at the University of Queensland, told the limbic data from the US and UK suggested about 30% of the population had fatty liver disease.

 “Yet when we asked GPs what they thought about its prevalence, about half of them reported its prevalence at less than 10%.”

Professor Powell said she believed there was still a lingering misconception that NAFLD was a benign condition.

“It’s like we thought initially with hepatitis C – that this was a mild condition that progresses very slowly. And yet 10, 15, 20 years on we realised that hepatitis C was a major cause of cirrhosis and liver cancer and needs to be treated. I think the same process is happening with NAFLD.”

She said NAFLD was recognised as the second leading cause of liver disease in the US and the second most common cause of primary liver cancer in adults awaiting liver transplant.

“We’d like to encourage people to consider the liver much earlier and when they see patients with risk factors like obesity, type 2 diabetes and metabolic syndrome, think ‘Could the liver also be involved?’”

Better alternatives to liver function tests

The survey also revealed that one quarter of GPs thought liver function tests were adequate to identify NAFLD despite their lack of sensitivity. About 70% of GPs reported they would not refer patients to a specialist unless their liver function tests were abnormal.

“About 70 to 80% of patients with NAFLD have relatively normal liver enzyme tests. What we’re trying to do is to educate people to use very simple scoring systems such as the NAFLD Fibrosis Score or FIB-4 Score which use simple tests and clinical features from everyday clinical practice.”

“Together these combinations of tests and clinical features have better predictive value for ruling out significant liver injury.”

Most GPs were also unsure about using the Enhanced Liver Fibrosis (ELF) test – a direct serum marker of fibrosis.

“This test is available privately with no Medicare rebate but is considered a first line test for GPs in the UK to assess the severity of fatty liver disease. While it’s not part of our guidelines yet and we are still assessing its utility, it may be useful in the future.”

Professor Powell said other tools such as transient elastography (FibroScan) had replaced some of the necessity for invasive tests such as liver biopsy.

“At the moment, FibroScan is usually limited to hospitals with a liver centre but ultimately if we get a Medicare rebate for this test, it will become more readily available and useful in assessing fatty liver disease severity.”

“We feel it’s important to identify patients who have a high risk of more significant liver disease and advanced scarring as these are the people who need to be followed up for complications such as cirrhosis of the liver.”

She said the cornerstone of treatment was still lifestyle modification however new pharmacotherapies were becoming available.

“There is now a lot of work going on repurposing drugs and developing new medications for fatty liver disease. It won’t be long before we do have new pharmacotherapies to offer people.”

She said gastroenterologists could provide support to help manage NAFLD in the community.

“What we’re hearing from GPs is that they really appreciate feedback and the letters we send back to GPs are very important in identifying the issues and making recommendations for management and follow-up, and when people might need to be re-referred.”