Endocrinologists and PCPs: The Frontline Defense Against Cirrhosis in Patients with Type 2 Diabetes 

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Ms. Janovsky:
Hi. This is CME on ReachMD. My name is Tessa Janovsky. I'm a PA at Arizona Liver Health in Phoenix, Arizona. As a PA in outpatient hepatology clinic, I see a wide variety of liver disease, including MASLD/MASH viral hepatitis, autoimmune liver disease, all the way to decompensated and compensated cirrhosis. So as a APP, I really think that APPs in primary care and endocrinology offices are going to play a vital role in identifying these patients that may be at risk for MASLD and MASH. And implementing screening protocols can really make a difference as far as catching these patients early before unfortunately, they may be at risk for more advanced fibrosis.

So first and foremost, we know that MASLD is underdiagnosed. There was, a study looking at four different European databases that show that the expected prevalence of MASLD was about 20 to 30% based on, risk factors, but only about 1.85% of patients actually had a real-world diagnosis of MASLD. So as you can see, there's a large gap between the expected prevalence of patients with MASLD and who actually receive a diagnosis of MASLD.

We know that MASLD is associated with a variety of metabolic comorbidities. These patients typically will have obesity, type 2 diabetes, hyperlipidemia, hypertension, metabolic syndrome. And they don't need to have all of these risk factors; they really only need to have one metabolic risk factor to be at risk for MASLD and possibly, advanced fibrosis. And MASLD is really the hepatic manifestation of obesity. And so, it's so important with the rise in the obesity epidemic, diabetes epidemic, is that we also think about the liver and whether these patients have any sort of liver disease.

The majority of these patients are going to be seen in the primary care and endocrinology practices, and so screening and detection of these patients in these care settings is going to be vital to the national MASH strategy, as far as finding these patients early. At the end of the day, MASLD and MASH is largely asymptomatic, unfortunately, until it's too late, until these patients have more, advanced fibrosis. And so, as I mentioned earlier, patients with at least one risk factor for, metabolic risk factor, are at risk for clinically significant fibrosis.

As far as screening recommendations for these patients, the screening recommendations are evolving, but we do have a couple available. we have recommendations from the American Association of Clinical Endocrinology, AACE, and then we also have from American Association on the Study of Liver Disease, or AASLD, who provide guidelines and recommendations for providers in the primary care and endocrinology settings.

And, first, we’ll go over, you know, step 1 and step 2 of these screening recommendations. And, the next section will go more in depth for, step 3 and step 4. But first, once you've identified patients at risk for clinically significant fibrosis, what happens next? So anybody with, metabolic risk factors like you know, diabetes, high blood pressure, high cholesterol, or hyperlipidemia. Or if a patient comes in, follows up in the primary care clinic and they see some steatosis on imaging, or if there's any elevation your liver enzymes, there should be, you know, a standard history taken. make sure there's not any excessive alcohol use on board.

And so once you've identified these patients, then the next step is to get some basic blood tests, and that's going to be a CBC and a CMP. And that's going to give you the platelet count and the, liver enzymes to where you can calculate a FIB-4. So the FIB-4 then will guide you whether somebody is low risk, intermediate, or high risk. And so that, will then guide you to what the next steps are. And, like we said, we'll go over step 3 and step 4 in more detail coming up. I hope you enjoyed this information and found it useful. Thank you so much for tuning in.

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