Approach to Fatty Liver Disease in Patients with Type 2 Diabetes

Type 2 diabetes is a major risk factor for development and progression of non-alcoholic fatty liver disease (NAFLD). Fatty liver is prevalent in people with type 2 diabetes, and overweight or obesity in these patients aggravates insulin resistance and steatohepatitis, which appear to be drivers for the disease progression. The goal of screening is not to identify steatosis itself, but rather to identify patients at risk for adverse hepatic outcomes such as cirrhosis, hepatocellular carcinoma, and death from liver disease. The most important risk factors for disease progression are liver fibrosis and its severity. There is a consensus that the FIB-4 (fibrosis-4 index) is the most cost-effective strategy for initial screening of hepatic fibrosis in a clinical setting. At present, there are no approved drugs for the treatment of NAFLD. Clinically significant improvements in NAFLD are achieved with weight loss. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium glucose cotransporter 2 (SGLT2) inhibitors are effective for inducing weight loss in patients with type 2 diabetes, and some GLP-1 RAs and SGLT2 inhibitors have been shown to be effective for treating steatohepatitis. Therefore, GLP-1 RAs and SGLT2 inhibitors should be considered when choosing antidiabetic agents in patients with type 2 diabetes and NAFLD, especially in those who are overweight or obese.