ADA: Screen All With Type 2 Diabetes for Fatty Liver Disease

27 Jun 2023 • The American Diabetes Association (ADA) now advises universal screening of people with type 2 diabetes and prediabetes for fatty liver disease and provides new recommendations for management in those with the condition, or who are at risk for it. The new ADA guidance was published June 24 as a mid-year update to the ADA's Standards of Care in Diabetes - 2023 in the section on "Comprehensive Medical Evaluation and Assessment of Comorbidities."

GUIDANCE ON SCREENING: The recommended screening tool is the fibrosis-4 index (FIB-4), a calculation that includes the patient’s age, liver enzyme levels, and platelet counts. A score of 1.3 or higher is considered high risk for clinically significant fibrosis, and above 2.6 is very high-risk.

"The reason we advise using the FIB-4…instead of liver enzymes as ADA advised in the past, is that now we know that 70% of people with type 2 diabetes have steatosis already and about one in five have fibrosis, but if you go by liver enzymes you will miss most of them. Liver enzymes are ineffective as a screening tool." noted Dr. Cusi, chief of endocrinology, diabetes, and metabolism at the University of Florida, Gainesville.

The ADA update also provides guidance on follow-up for patients flagged with the FIB-4, including when referral to a gastroenterologist or hepatologist is appropriate.


  • Lifestyle modification is recommended for all adults with diabetes or prediabetes and NAFLD, particularly those with overweight or obesity.
  • In addition, the ADA now advises consideration of a using a glucagon-like peptide 1 (GLP-1) agonist with demonstrated benefits in NAFLD as adjunctive therapy to lifestyle interventions for weight loss in those with type 2 diabetes, particularly with overweight/obesity.
  • And for those with biopsy-proven NASH or who are identified with clinically significant liver fibrosis using non-invasive tests, either a GLP-1 agonist or pioglitazone are the "preferred treatments."
  • However, insulin is the preferred treatment for hyperglycemia in adults with type 2 diabetes who have decompensated cirrhosis.
  • The ADA update also advises statin therapy for people with type 2 diabetes and NAFLD, given their increased cardiovascular risk.

Source: ADA Meeting News | Read full story

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