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As the NASH pandemic grows in the number and diversity of patient cases, one patient group receiving increased notice includes patients with "lean NASH," those with "normal" BMI levels (BMI<23 for Asians; BMI<25 for other racial groups). Last month, Gastroenterology published Best Practice recommendations for diagnosing and treating lean NASH. In this conversation, co-authors, Drs. Michelle Long and Mazen Noureddin join Louise Campbell and Roger Green to discuss why early diagnosis is so important for patients with lean NASH, which has a subtly different focus than other forms of NASH.

This conversation harkens back to the previous week (Season 3, Episode 39) and Ian Rowe's analysis of different early diagnostic techniques and assessment that "Fibrosis First" was the most cost-effective and highly effective way to identify patients at risk. Roger points out that Fibrosis First looks very similar to what Mazen and Michelle recommend here. For this population, he asks how to identify lean patients that need this kind of workup.

Mazen states that the key marker is an extremely high ALT level (40 or 50 would not create this level of scrutiny, but 80 or 90 would.) Michelle agrees, but adds that most patients are diagnosed when they appear with some level of decompensating cirrhosis. As a result, she suggests that a primary care physician probably does not need to evaluate any patient they would not already consider at high risk: Type 2 diabetes or very high ALT levels. She also indicates that "Fibrosis First" sounds like an intriguing approach and that she needs to find Ian's poster or hear the podcast.

Michelle also comments that primary care physicians might be uncomfortable or intimidated screening for cirrhosis, which they do not feel qualified to treat. Louise asks whether they might be more comfortable assessing liver health vs. screening for cirrhosis.

Roger asks what else a hepatologist might take out of this paper. Michelle repeats their strong call for more research with this population, while Mazen points to Table Two in the publication as a comprehensive list of the various other conditions physicians need to screen for. Further, he notes that by placing the entire diagnostic pathway in a single chart, he empowers a hepatologist or gastroenterologist to approach primary care physicians and delineate which parts of the algorithm are the domain of which specialty. (The chart color codes this issue, with the pre-specialist elements in blue and hepatgologist elements in green.)

Finally, Mazen points out that when he sees lean NASH patients, he tries to place them in clinical trials, which can benefit the individual patient and generally advance our understanding of how to treat this condition.