Suggested Reading: Combination therapy with pioglitazone/exenatide/metformin reduces the prevalence of hepatic fibrosis and steatosis: The efficacy and durability of initial combination therapy for type 2 diabetes (EDICT) / https://bit.ly/3L7vuzK

This conversation includes part of a longer discussion that Naim Alkhouri had with Louise Campbell and Roger Green when he stopped by the virtual SurfingNASH.com studios to discuss his recent work.

Naim dives right into the conversation by mentioning that he has had two papers published within the last week or two. One is from the EDICT Trial, a multi-year evaluation of Type 2 Diabetes patients where half are randomly assigned a course of “conventional” step therapy, and the others are assigned an immediate course of a more up-to-date combination therapy. The conventional therapy includes metformin, followed by a sulfonylurea and eventually insulin. The more up-to-date therapy also includes an initial therapy including metformin along with pioglitazone (which has known effects on diabetes and NASH) and exenatide, an anti-obesity medication. After six years, 69% of the convention therapy group exhibited moderate-to-severe steatosis vs. 31% of the combination therapy group. Further, 26% of the conventional therapy group exhibited F3 or F4 fibrosis vs. 7% of the initial combination therapy group. The other paper involved an analysis of the NHANES database. Using a CAP score cutoff of 3.02, the analysis estimated NAFLD prevalence of 25% and F2 or higher fibrosis of 4.4%. Among Type 2 diabetes patients, the corresponding numbers were 54% and 18%. Naim talked about additional work this study team will do in analyzing the database.

Louise Campbell asks whether the group considered CAP scores of 2.48. 2.60 and 2.83, which are used in some of the meta-analyses. Naim responds that the lowest CAP (2.48) would double the NAFLD estimate to something more like 50% and felt too low a CAP. We come back to this issue in Conversation 21.3.

I close this conversation with the comment that these studies collectively suggest that regardless of whether we find NAFLD or NASH in a T2D patient, we should treat them all as if it is or could be present. Naim agrees, saying that these studies tell him that as a society, we should take Type 2 Diabetes far more seriously and should pressure the medical societies to do the same.