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

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Dr. Alkhouri:
This is CME on ReachMD, and I'm Dr. Naim Alkhouri, the Chief Medical Officer and the Director of the Steatotic Liver Program at Arizona Liver Health in Phoenix, Arizona. In Episode 2, we discussed steps 1 and 2 of the American Gastroenterology Association Care Pathway for identification and risk stratification of patients with a risk of MASLD. Now we are going to discuss step 3.

And as a reminder in step 1, we will look at patients at risk of having MASLD and advanced fibrosis. So these are patients with type 2 diabetes those with metabolic syndrome, and any patients with elevated transaminases or evidence of steatosis on imaging. So this is the first step, is to identify at-risk patients. The second step is to take a good history and assess for excessive alcohol consumption. Also obtain a complete blood count and liver enzymes, so we can actually move on to step 3.

Step 3 is really to risk stratify patients and calculate a score we call the FIB-4 index. FIB-4 is very simple to calculate. All you need is the age of the patient. As patients get older, they have higher risk of having advanced disease, the AST to ALT ratio, because in patients with advanced disease, the AST becomes higher than ALT, and then the platelet count, because the platelet count goes down as patients progress to cirrhosis and clinically significant portal hypertension. It's a very simple calculation, and it has good prognostic value also for patients with MASLD, and there are several online calculators.

The way we interpret FIB-4, if the value is less than 1.3, this is considered lower-risk patient that can be managed in the primary care settings. If the FIB-4 is more than 2.67, this is considered high-risk patient that should be referred to as specialist. And then, if the FIB-4 is between 1.3 to 2.67, this is considered indeterminate score, and this is the time to do a sequential, non-invasive test to risk stratify this patient.

Now, based on the FIB-4 values, we have management strategies for our patients. So for patients with low FIB-4, less than 1.3, this is considered, again, lower risk, management should be done by primary care physician. For all-risk categories, we need to recommend the lifestyle intervention focused on weight loss, ideally 10% of total body weight. We should also discuss cardiovascular risk reduction, giving the high cardiovascular disease burden in patients with MASLD. but then in patients with lower risk, in terms of weight loss, we focus on structured weight loss program, but for patients with intermediate risk and high risk, we should strongly consider antiobesity medications. For a patient with a lower risk, there is no recommendation to use pharmacologic treatment but this is actually indicated in patients with intermediate and high risk. And we recently have an FDA approved medication to treat patients with MASH and stage 2 and 3 fibrosis.

When it comes to also selecting diabetes medications in patients that are lower risk based on FIB-4 less than 1.3 we follow standard of care, but once you get to intermediate and high risk you should preferentially use medications that may have a positive impact on MASLD and MASH specifically glucagon-like peptide 1 receptor agonists such as semaglutide. You may also consider dual agonists such as tirzepetide and also pioglitazone, which has been shown in a few clinical trials to have beneficial effects on MASH histologic severity.

So my takeaway message is that calculating FIB-4 should be the third step in the algorithm, after we identify patients at risk and rule out excessive alcohol consumption. And then based on the FIB-4 values, we risk stratify patients into lower risk, intermediate risk, and high risk. And then the management strategy would be based on the risk category the patient is in. Thank you.

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