LIZ: Welcome back to the Southeastern Ohio Quality Improvement Hub video series. My name is Dr. Adkins, and I'm happy to be here with our favorite diabetologist, Dr. Amber Healy. I may look a little different to you. I got a hairdo. 

I'm kidding. My name's Liz Beverly. I'm filling in for Sarah Adkins. It's July. People go on vacation. Sarah's a little busy this month, so I'm here to fill in. So, Dr. Amber Healy, I heard we're talking about the liver. 

AMBER: We are talking about the liver today. 

LIZ: Why are we talking about the liver for type 2 diabetes? 

AMBER: Well, there's a couple of reasons. We can go back to basics like we do with the med students. Liver is one of the Ominous Octet, terrible triumvirate even in the past, and now, oh my gosh, we're up to like the terrible 13, I don't know. But it is definitely involved in glucose regulation. But more specifically today, we are concerned about the liver because there's an emerging health issue, metabolic associated steatotic liver disease, that is more common in our patients with type 2 diabetes. 

LIZ: I don't think I could repeat that. So is there an acronym for it? 

AMBER: MASLD. 

LIZ: MASLD. Okay. I think I've heard of MASLD, but it used to be called something else. 

AMBER: Yes. In the past, people referred to it as NAFLD or NASH, which was non-alcoholic fatty liver disease. So they decided a couple of years ago that they wanted to name change because alcohol made things confusing when you say non-alcoholic. And then fatty sounded a little stigmatizing, so adding the steatosis or steatotic sounded more scientific, and metabolic really described it better than saying non-alcoholic. 

LIZ: I think that's a good thing, right? 

AMBER: I think so, too. Yeah. 

LIZ: So how common is MASLD in people with diabetes? 

AMBER: They've estimated that up to 70% of people with type 2 diabetes are affected by MASLD.

LIZ: 70% that is a lot of people with diabetes. It's interesting because I feel like I've only really heard about MASLD in the last couple of years. If it's already affecting 70% of people, it seems like this is something that should've been talked about for a long time. 

AMBER: It's been under-recognized, for sure. And in the last couple of years, there have been more guidelines that have come out to help guide physicians and other healthcare providers in the screening for it and treatment of it. I know that I had patients with it in the past that we didn't know they had it. May have had really well-controlled glucose. A1c, no problems. Lab work didn't show any problems. And I had a patient that their first indication of this was that they had a GI bleed and had varices in their esophagus that were bleeding because they already had cirrhosis. 

LIZ: Wow. So what are the clinical risk factors for people with MASLD? 

AMBER: So type 2 diabetes, which we have started this conversation with pre-diabetes- and obesity are three metabolic indications for taking a closer look for MASLD. 

LIZ: Okay. So this is something that's super common, and since we have a lot of people in our region with type 2 diabetes, what can physicians in our region do to screen for it? 

AMBER: Well, we can start with continuing our yearly lab work. I know most people with diabetes are getting yearly lab work. People that go and see primary care should be getting yearly lab work. And part of that includes a comprehensive metabolic panel. So that'll include the liver enzymes, the AST and the ALT. They should also be considering getting a CBC, which is a complete blood count. That includes a platelet count. And actually, those two tests alone have the pieces of information you need to calculate a FIB-4 score because you already have the patient's age. 

LIZ: Okay. FIB-4, tell me more. 

AMBER: So the FIB-4 is a score that has been used for other types of liver conditions that more recently they've been noticing is a nice way to screen and see if somebody has higher risk of progression to fibrosis and metabolic associated steatotic liver disease. It includes the age and the AST in the numerator. And then the platelets and the ALT are in the denominator, and there's actually calculators online. There's one called MDCalc that- 

LIZ: That's a relief because if everybody had to do the math, I'm not sure people would want to do that. 

AMBER: Probably not. One thing I've even found, it's kind of a challenge to open another window, too, when you're in a patient encounter- Sure ... or labs come in, is trying to get the equation built into the electronic record so that way it'll self-calculate for you. The cut score is a 1.3 for indication- to go on and do imaging. If it's over 2.67, you're supposed to automatically refer to GI. Okay. And then if it's under that 1.3, they recommend just rechecking again yearly. 

LIZ: Okay, so cutoff score 1.3, and if it's above 2.7, that's when you refer to GI. If it's below 1.3, you just do another check in a year. 

AMBER: M-hmm.

LIZ: Okay. That's pretty easy to follow. Now, does the FIB-4 work for everyone? 

AMBER: It doesn't. It's got pretty good sensitivity and specificity for the population that it's been studied in, but it hasn't been studied in adults under the age of 35, or anybody under the age of 35. And it hasn't really been studied in 65 and older, but the current recommendation is that if the score is two and higher in someone who's over the age of 65, you should proceed with additional imaging testing. 

LIZ: Okay. Now, are there other tests for the liver that people should know about, like other types of scans? 

AMBER: So traditionally, before these guidelines come out, a lot of people just do an ultrasound. Ultrasound will tell you that there's fat in the liver, which, great, we know you have fat in the liver, but there are now FibroScan. There's this vibration controlled transient elastography measure. 

LIZ: That's a mouth full. 

AMBER: I know. You're testing my ability to say words today. 

LIZ: Yes, I am. 

AMBER: But the VCTE, most well-known as FibroScan. It is a type of ultrasound, but because it measures the vibrations with a specific type of probe, it can tell you how much fibrosis is in the liver, and it helps you stage, too, whether or not they have F2, F3, or F4 fibrosis stages, which helps guide next steps in treatment. 

LIZ: Can you explain to me the staging of fibrosis, and why do we care about fibrosis as it relates to the liver? 

AMBER: Well, more fibrosis means there's more progression towards cirrhosis. 

LIZ: Okay. And that's not a good thing. 

AMBER: No. 

LIZ: Got it. So you identify that, you do the scans, and you either find out if somebody has fibrosis, different staging. What do you do if you find fibrosis? How do you treat somebody? 

AMBER: Well, some people go ahead and refer to GI or hepatology. And if that's your comfort level, that is perfectly fine because they've got the scans, they have familiarity with the treatment. Otherwise, you may want to go ahead and prescribe semaglutide. 

LIZ: Oh, great. 

AMBER: Semaglutide is FDA approved for treatment of MASLD.

LIZ: It's hard to remember the name change, right? 

AMBER: MASLD. It's been approved for use there, and then there's actually a novel medication called resmetirom- that is also indicated for the treatment of MASLD. 

LIZ: Great. Are there other medications in the pipeline? 

AMBER: There are other things that are currently being studied. There are older medications that have been used in the past that have shown some benefits, not just looking at the liver, but histologically. But they're definitely studying other things right now to see what else can be used. 

LIZ: So stay tuned. We may be back. All right. So we have some medications. What are some behaviors that people can do? 

AMBER: Well, weight loss does improve liver histology as well. So the recommendation is about 7% to 10% weight reduction, and that can be done through lifestyle changes. Plant-based whole food diets are helpful, especially Mediterranean has some data. There's been a study that has actually shown some improvement with going on a Mediterranean diet for MASLD. And then increasing activity level is always helpful. 

LIZ: Right. Okay. So things that we've been saying all along, right? Healthy eating, plant-based whole foods, increasing physical activity levels. What else? Are there any other behaviors? What about alcohol? We're talking about the liver. 

AMBER: Yes. If somebody comes back with a fibrosis score that converts to an F2, you should probably advise them not to imbibe. 

LIZ: Okay. That does make sense. Correct. Yes. All right. So I feel like I've learned a lot about the liver, so this has been really helpful. What would you say are some key takeaways from this conversation? 

AMBER: I'd say the biggest things to keep in mind compared to previous thought processes would be to consider this as part of annual screening for complications. I tend to frame it as I'm checking eyes, I'm checking the kidneys, I'm checking feet, I'm going to check the liver while I'm at it because I always do yearly labs, so it's another thing you can incorporate. The FIB-4 score is a great place to start, so you can categorize where you're going to go next. And then, the FibroScan or that VCTE is an important imaging modality to use, not just an ultrasound, so you can get the fibrosis. And then one thing I didn't mention is if you can't get to the fibrosis, the FibroScan or the VCTE, is there is backup lab. There is lab work you can do alternatively. There's something called the enhanced liver fibrosis test. 

LIZ: Okay. 

AMBER: And it's a panel that's available through Quest and LabCorp. It includes three markers, and they do the equation for you, and you get a score in it if you're in a VCTE desert. 

LIZ: It's great to know that there's another option if people don't have the FibroScan. So thank you so much for spending time with me today. I really appreciate. You're our favorite physician. We love talking to you. Thanks so much for being with us. Just a little hint, you could do a PDSA on the FIB-4, just in case you're interested, and Sarah and Laurie would be happy to help you. I hope next time you get to see Dr. Atkins. So thank you so much. Good night and good luck.