NAFLD/NASH: Rising Prevalence and the Treatment Challenges in the Middle East

Liver disease is swiftly becoming a health priority worldwide, with various liver conditions posing significant challenges. The wide range of conditions, including viral hepatitis, alcoholic liver disease, nonalcoholic fatty liver disease (NAFLD), liver cirrhosis, and hepatocellular carcinoma (HCC), affect millions of people, causing significant morbidity, mortality, and economic implications. Among these liver conditions, NAFLD/nonalcoholic Steatohepatitis (NASH) stands out as a major contributor in the Western world. The growing prevalence of these in the MENA region has drawn the attention of epidemiologists and researchers as associated risk factors such as overweight/obesity, type 2 diabetes mellitus (DM), and metabolic syndrome rise as well.

NAFLD is divided into two categories, NAFL (steatosis only) and NASH. Liver inflammation due to these may advance to liver fibrosis, an important risk factor in developing decompensated cirrhosis and hepatocellular carcinoma (HCC). A study by Younossi et al. (2016) estimated that the prevalence of NAFLD in the Middle East was as high as 32%, the highest among global countries. More than NAFLD, chronic viral hepatitis B (HBV) and C (HCV) have historically been the main causes of chronic liver disorders in Saudi Arabia, with chronic viral hepatitis accounting for the majority of liver transplants from 2001 to 2010 (HBV 41.9%, HBV 21.1%). However, the prevalence of viral hepatitis in the KSA has significantly decreased due to the control of hepatitis B through vaccination programs and the advent of hepatitis C anti-virus therapy. The prevalence of NAFLD has increased due to the rising epidemic of obesity, diabetes, and metabolic illnesses. Furthermore, according to data from the World Health Organization (WHO), obesity rates among adults are exceptionally high in the MENA region, at more than 35% in KSA, 37% in the UAE, 32% in Qatar, and almost 40% in Kuwait.

NASH is a histological variant of NAFLD with signs of hepatocyte damage like hepatocyte ballooning. About   20% to 30% of individuals with NAFLD progress to NASH. Fibrosis, cirrhosis, and even hepatocellular cancer can develop from NASH. In Saudi Arabia and the UAE, the prevalence of NASH was 4.2% and 4.1% of the total population in 2017, respectively, and is anticipated to increase by 96% and 87% by 2030. In several Gulf nations, NASH is currently regarded as the main cause of liver transplantation. The compiled statistics indicate that the disease burden related to NAFLD and NASH in the Middle East region is increasing; hence there is a pressing need to enhance patient outcomes for diagnosis and treatment.

A liver biopsy that shows steatosis, hepatocyte ballooning, and lobular inflammation can identify NASH. Diagnosis guidelines also advise determining the surrogate fibrosis markers (NFS, FIB-4, ELF, or FibroTest) in NAFLD patients to rule out severe fibrosis (F2). Transient elastography/fibroscan should be performed on patients in whom considerable fibrosis cannot be ruled out, and liver biopsy should be used to confirm the diagnosis in those with significant fibrosis, which has been verified.

Despite these recommendations, physicians in the MENA region face numerous challenges in properly diagnosing NAFLD/NASH.

1. Lack of awareness: Early detection and diagnosis may be hindered by a lack of knowledge regarding NAFLD and NASH among the general public and healthcare professionals. Due to a lack of understanding, the problem may be underestimated or incorrectly diagnosed, delaying treatment and possibly having worse effects.
2. Lack of visible signs: NAFLD is frequently associated with lean people in the MENA region, who may not show visible signs of obesity or metabolic syndrome. As a result, symptoms like fatigue, stomach pain, or abnormal liver tests may not be quickly associated with liver illness resulting in a delay in diagnosis and treatment.
3. Diagnostic techniques: One often utilized imaging technique for identifying liver illnesses such as NAFLD is abdominal ultrasonography. However, a lack of comprehensive training among gastroenterologists in the Gulf region may result in variances and potential inconsistencies in interpretation and results that may be subjective or subject to error. This would make diagnosis more difficult to identify liver pathology accurately.
4. Overlapping risk factors: Risk factors for NAFLD and NASH, such as obesity, type 2 diabetes, and metabolic syndrome, are common in the Middle East. However, these risk factors co-occur with other common diseases, making it difficult to link specific symptoms to NAFLD or NASH.
5. Variability in disease presentation: NASH can manifest in numerous ways in different people, from a modest fatty liver to a severe case of fibrosis and inflammation. Because of this heterogeneity in disease presentation, it can be difficult to identify NASH based solely on clinical symptoms correctly.

Furthermore, only 10% of patients in the MENA region prefer to opt for liver biopsies. Physicians in the region consider liver biopsy a last resort, sometimes waiting for nearly 5 years post-diagnosis until signs of elevated liver biomarkers appear and lifestyle changes show no improvements in patients. This leads to disease progression from one stage to another, ultimately adversely impacting the patient’s quality of life. Therefore, it is clear that there is a large unmet need to enhance the region’s diagnostic capabilities for NAFLD and NASH.

Given the increasing prevalence of NASH and NAFLD in the Middle East, addressing these concerns on a regional level is essential. To achieve this objective, advisory board meetings were held between May 2018 and February 2019 in Saudi Arabia, UAE, and Kuwait. The purpose of these meetings was to discuss the current local challenges related to NASH screening and diagnosis and explore the different available management options. The experts deliberated on the following subjects: (1) The prevalence and impact of NAFLD/NASH in the Middle East; (2) Approaches to screening, diagnosing, and referring individuals with NAFLD; and (3) The various treatment choices accessible for NAFL and NASH.

During the meetings, the experts emphasized the need to effectively address the challenges confronting the medical community with comprehensive and widely embraced national (or regional) NAFLD initiatives. These included raising awareness, providing education, prioritizing prevention efforts, establishing early detection programs, and implementing evidence-based, cost-effective care algorithms.

However, there is still a long way for these initiatives to be implemented. Nonetheless, numerous physicians preferred to adopt diagnostic tests with the guidelines recommended by the European Association for the Study of the Liver (EASL). These guidelines are believed to be well-suited to address the distinct requirements of patients in the Middle Eastern region.

The management of NAFLD and NASH presents significant difficulties in the Middle East. There is continuous discussion among physicians regarding whether screening for NAFLD/NASH should be done on at-risk individuals without authorized, efficient pharmaceutical treatment alternatives. High-risk group screening might be a more feasible solution in such a situation. Additionally, questions about how to refer, treat, and monitor these individuals appropriately exist. No particular medications have been approved for the management of NAFLD/NASH. Treatment entails controlling risk factors like type 2 diabetes and obesity-related to the condition. To best manage these risk factors for NAFLD, medications being utilized to treat obesity and type 2 diabetes can be used. A few off-label medications, such as antioxidants and insulin sensitizers, are recommended only in biopsy-proven NASH patients with significant fibrosis. In addition, patients at high risk of disease progression but at less severe stages of the disease may still be candidates for treatment.

Since there is no approved therapy for treating NASH, current management relies heavily on lifestyle changes that are difficult to start and maintain. Many novel treatments are currently being developed and are eagerly awaited. The existing landscape of NAFLD treatment choices could be significantly improved by the availability of potent pharmaceutical treatments.

Physicians’ or experts’ opinions:

“We must first increase our knowledge about NAFLD/NASH, including who is affected, how the illness progresses, and the best ways to treat it.” 

–Consultant Transplant Hepatology

“We have to set up new multidisciplinary models of care for NAFLD and NASH patients.”

–Specialist in Endocrinology

“We must add liver conditions in public health policies and take initiatives to prevent or reduce obesity, especially among children and young people.”

–Gastroenterology Expert

Source: Delveinsight http://www.delveinsight.com/