title: Practice patterns in NAFLD and NASH: real life differs from published guidelines.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: 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.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Rinella
authors.affiliation: Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
authors.forename: Zurabi
authors.initials: Z
authors.lastname: Lominadze
authors.affiliation: Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla CA, USA.
authors.forename: Rohit
authors.initials: R
authors.lastname: Loomba
authors.affiliation: Intermountain Medical Center, Salt Lake City, Utah, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Charlton
authors.affiliation: Division of Gastroenterology and Hepatology, St Louis University, St Louis, Missouri, USA.
authors.forename: Brent A
authors.initials: BA
authors.lastname: Neuschwander-Tetri
authors.affiliation: Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA.
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Caldwell
authors.affiliation: Division of Gastroenterology and Hepatology, Swedish Hospital Medical Center, Seattle Washington, USA.
authors.forename: Kris
authors.initials: K
authors.lastname: Kowdley
authors.affiliation: Division of Gastroenterology and Hepatology, Brooke Army Medical Center, San Antonio, Texas, USA.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Harrison
keywords: diagnosis; liver biopsy; nonalcoholic fatty liver disease; nonalcoholic steatohepatitis; pioglitazone; practice guidelines; practice patterns; treatment