Rinella Mary E, Lominadze Zurabi, Loomba Rohit, Charlton Michael, Neuschwander-Tetri Brent A, Caldwell Stephen H, Kowdley Kris, Harrison Stephen A
Associate Professor of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Arkes Pavillion 14-012, Chicago, IL 60611, USA.
Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Therap Adv Gastroenterol. 2016 Jan;9(1):4-12. doi: 10.1177/1756283X15611581.
Management guidelines from the American Association for the Study of Liver Diseases/American College of Gastroenterology/American Gastroenterology Association published in 2012 for nonalcoholic fatty liver disease (NAFLD) and steatohepatitis (NASH) recommend weight loss, vitamin E and pioglitazone as effective therapies for the treatment of biopsy-confirmed NASH. However, little is known about how physicians in the US diagnose NASH or whether published guidelines are being followed.
We assessed current diagnostic and treatment patterns of the management of NAFLD and NASH among academic gastroenterologists and hepatologists in the US using a standardized survey developed to collect information regarding respondents' practice environments, diagnostic techniques, and medication usage in patients with NAFLD/NASH.
We invited 482 gastroenterologists and hepatologists, predominantly from academic centers, of whom 163 completed the survey. Only 24% of providers routinely perform liver biopsy, predominantly among patients with elevated serum aminotransferases. Vitamin E is prescribed regularly by 70% while only 14% routinely prescribe pioglitazone. Despite recommendations to the contrary, ~25% prescribe pioglitazone or vitamin E without biopsy confirmation of NASH. Metformin is used as frequently as pioglitazone despite its proven lack of efficacy in NASH. Overall, 40-73% adhere to published guidelines, depending on the specific question. There was no significant difference seen in adherence to guidelines between gastroenterologists and hepatologists.
This survey suggests that clinical practice patterns among gastroenterologists and hepatologists for the management of NASH frequently diverge from published practice guidelines. Although liver biopsy remains the gold standard to diagnose NASH, less than 25% of respondents routinely require it to make the diagnosis of NASH. We conclude that NASH is underdiagnosed in gastroenterology and hepatology practices, highlighting the need to refine noninvasive diagnostic tools.
美国肝病研究协会/美国胃肠病学院/美国胃肠病协会于2012年发布的非酒精性脂肪性肝病（NAFLD）和脂肪性肝炎（NASH）管理指南推荐，减肥、维生素E和吡格列酮是治疗经活检确诊的NASH的有效疗法。然而，对于美国医生如何诊断NASH以及他们是否遵循已发布的指南，人们知之甚少。
我们使用一项标准化调查评估了美国学术性胃肠病学家和肝病学家对NAFLD和NASH的当前诊断和治疗模式，该调查旨在收集有关受访者的执业环境、诊断技术以及NAFLD/NASH患者用药情况的信息。
我们邀请了482名胃肠病学家和肝病学家，主要来自学术中心，其中163人完成了调查。只有24%的医疗服务提供者常规进行肝活检，主要是在血清转氨酶升高的患者中。70%的人定期开具维生素E，而只有14%的人常规开具吡格列酮。尽管有相反的建议，但约25%的人在未通过活检确诊NASH的情况下就开具吡格列酮或维生素E。尽管已证实二甲双胍对NASH无效，但它的使用频率与吡格列酮相同。总体而言，40%-73%的人遵循已发布的指南，具体比例取决于具体问题。胃肠病学家和肝病学家在遵循指南方面没有显著差异。
这项调查表明，胃肠病学家和肝病学家对NASH的临床实践模式常常与已发布的实践指南不一致。尽管肝活检仍然是诊断NASH的金标准，但不到25%的受访者常规要求进行肝活检以诊断NASH。我们得出结论，在胃肠病学和肝病学实践中，NASH的诊断不足，这凸显了改进非侵入性诊断工具的必要性。
