Given the vast amount of information and insight from The Liver Meeting, this episode sought to identify and explore a few key highlights. The panel (Jörn Schattenberg, William Alazawi, Naim Alkhouri, Laurent Castera, Ken Cusi, Wayne Eskridge and Roger Green) addresses several topics from the program.
Comparing Global Health Systems, Standardizing AST and Educating on NAFLD Prevalence
Ken leads this conversation with an analogy from the diabetes field. He describes the impact of albumin screening in urine on helping primary care treaters focus on diabetes screening and, ultimately, providing better information to patients. He shares his hope that a simple test, like FIB-4, will illuminate direction in the recent guidelines for liver diagnostics. Will suggests a few additional challenges face Fatty Liver disease. Treaters have one hand tied behind their backs because basic blood panels and screens do not provide the information necessary for algorithms to seamlessly assess liver health. He adds that “not having that information at your fingertips is one thing, but not knowing what to do with it afterwards is something else.”
Ken notes most patients in the US healthcare system receive an annual metabolic profile which often includes liver enzymes and a complete blood count. As such, he emphasizes the importance of educating on how to build the right equations into medical records. Roger notes a significant barrier: the US is one of the only countries whereby AST is standardized. It is frequently implored on this podcast that patient advocates outside the US make standardized testing for AST a priority. This is especially important for all diabetic patients.
Laurent Castera describes the French system which provides free medical checkups, but does not measure for AST. He suggests a problem that in France, doctors generally still link cirrhosis to alcohol and not NASH. As a result, they may not see the value in screening patients who do not consume alcohol. It’s noted that identifying patients with advanced fibrosis is critical even in the absence of pharmacological treatment. Ken points out that there are drugs for obesity and diabetes that also help in NASH, like pioglitazone and the GLP-1 agonists. With steps to help patients beyond diet and exercise, it is important to educate primary care to test for NASH.
As the conversation winds down, Naim provides two pieces of encouragement. The first, from a resmetirom open-label cirrhosis study, suggested that the drugs in development and close to market today may provide benefit for cirrhotic patients. The second, more encouraging to payers, came from a study he conducted with colleagues to assess how much burden the AGA pathway would place on the US system. The result: only 8% of patients would need to be treated by a hepatologist. This suggests that even with nearly 100 million people with NAFLD, only 4-5 million would require expensive NASH drugs.