Surfing the MASH Tsunami

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Back in March 2023, Jeff McIntyre (GLI) introduced a draft report from the Institute for Clinical and Economic Review (ICER) on resmetirom and obeticholic acid for NASH. The Surfers dedicated an episode to expand on the contents, its shortcomings and potential implications with special guests Veronica Miller (Liver Forum) and Hannah Mamuszka (Alva10). This week, SurfingNASHrevisits the topic after a public comments session took place last week. In doing so, patient advocates and friends of the podcast Mike Betel (Fatty Liver Alliance), Tony Villiotti (NASHkNOWledge) and Wayne Eskridge (Fatty Liver Foundation) join co-hosts Louise Campbell and Roger Green to share a range of impressions.

00:00 Introduction

05:28 How did each come to give commentary and be involved in the events of last Friday?

09:46 Reactions to the word 'empathy' in context of the discussion

17:58 The role of biopsy and economics of diagnosing patients

25:19 What motivated each patient advocate to deliver the testimonies which they specifically chose to?

34:00 The role of ICER , the FDA and final thoughts

Tune in for the full extent of the insightful discourse. If you enjoy the episode, have questions or interest around patient advocacy and Fatty Liver disease, we kindly ask that you submit reviews wherever you download the discourse. Alternatively, you can write to us directly at [email protected].

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The paper “Clinical Care Pathway for the Risk Stratification and Management of Patients with Nonalcoholic Fatty Liver Disease” is a clarion call to action, but what exactly should clinicians do? This conversation From the Vault addresses that issue. Louise Campbell starts by stating that the World Health Organization should incorporate Fatty Liver disease into their diabetes initiative. Next, she leads the group into a discussion of the merits of transient elastography, which leads Ken Cusi and Stephen Harrison to discuss blood-based and imaging options clinicians can deploy when they lack access to a FibroScan or similar device. Finally, Roger asks the most important step stakeholders should take now, which provide an array of different actions.

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As part of our ongoing dialogue around clinical care pathways and the complex of metabolic diseases, SurfingNASH dedicates a session to focus on the key relationship and interplay between endocrinology and hepatology. This topic rings familiar in the Rising Tide series, our podcast for frontline education, where Ken Cusi often notes the need for endocrinologists to become comfortable diagnosing Fatty Liver disease (and prescribing pioglitazone) and for hepatologists to become more comfortable prescribing GLP-1s. To expand on these critical ideas with the SurfingNASH community, Jörn Schattenberg, Louise Campbell and Roger Green are joined by Cyrielle Caussy, Professor of Nutrition and Endocrinologist-Diabetologist at Lyon 1 University and Lyon South Hospital, Hospices Civils de Lyon (France). Cyrielle is an expert in the clinical care of metabolic disease, including type 2 diabetes, obesity and NAFLD, and she is leading a clinical and research program focused on metabolic liver disease at the Lyon Hepatology Institute.

This conversation begins with Jörn concurring with Cyrielle's statement about the importance of regular interaction and communication. Roger also agrees before asking Jörn for what he considers to be key in getting liver patients picked up earlier by endocrinologists, primary care or even gastroenterologists. Jörn replies that this specific health system pathway will matter, but the role of nurse practitioners will be the key. He also emphasizes the importance of offering better information to patients. Finally, he says we need to stress that there are things physicians can do with these patients and this will become easier to discuss once drugs have been approved. Louise notes that this aligns with her focus on the role of allied health providers. She goes on to comment on the value of VCTE in identifying disease in all kinds of different patients. Jörn adds that at least once a week he is asked to consult on a patient whose unrelated surgery led to a decompensating cirrhotic event. As the session winds down, Roger asks the panelists what they would do if they had a magic wand to touch one thing in their hospital to make a change. Listen on to hear their varying and surprising answers.

If you enjoy the episode, have questions or interest around endocrinology and Fatty Liver disease, we kindly ask that you submit reviews wherever you download the discourse. Alternatively, you can write to us directly at [email protected].

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Send us Fan Mail

As part of our ongoing dialogue around clinical care pathways and the complex of metabolic diseases, SurfingNASH dedicates a session to focus on the key relationship and interplay between endocrinology and hepatology. This topic rings familiar in the Rising Tide series, our podcast for frontline education, where Ken Cusi often notes the need for endocrinologists to become comfortable diagnosing Fatty Liver disease (and prescribing pioglitazone) and for hepatologists to become more comfortable prescribing GLP-1s. To expand on these critical ideas with the SurfingNASH community, Jörn Schattenberg, Louise Campbell and Roger Green are joined by Cyrielle Caussy, Professor of Nutrition and Endocrinologist-Diabetologist at Lyon 1 University and Lyon South Hospital, Hospices Civils de Lyon (France). Cyrielle is an expert in the clinical care of metabolic disease, including type 2 diabetes, obesity and NAFLD, and she is leading a clinical and research program focused on metabolic liver disease at the Lyon Hepatology Institute.

Louise leads this conversation with a question around designing a more comprehensive metabolic blood profile in light of the vastness of metabolic syndrome and diseases. Jörn responds that while a metabolic screening would be of strong research interest, the message discussed in this episode champions simplicity, practicality and the ability to empower physicians for the identification and risk stratification of their patient population. From here, Cyrielle describes discovering patients with NAFLD-driven diabetes and the implications that various subtypes have on disease prognosis.

Jörn takes an amusing turn to a recently published article in Nature which points to liver disease, viral hepatitis and alcohol consumption as causes of the composer Beethoven’s demise. Tune in to the full conversation to learn more about this unique case.

If you enjoy the episode, have questions or interest around endocrinology and Fatty Liver disease, we kindly ask that you submit reviews wherever you download the discourse. Alternatively, you can write to us directly at [email protected].

Stay Safe and Surf On!

Send us Fan Mail

As part of our ongoing dialogue around clinical care pathways and the complex of metabolic diseases, SurfingNASH dedicates a session to focus on the key relationship and interplay between endocrinology and hepatology. This topic rings familiar in the Rising Tide series, our podcast for frontline education, where Ken Cusi often notes the need for endocrinologists to become comfortable diagnosing Fatty Liver disease (and prescribing pioglitazone) and for hepatologists to become more comfortable prescribing GLP-1s. To expand on these critical ideas with the SurfingNASH community, Jörn Schattenberg, Louise Campbell and Roger Green are joined by Cyrielle Caussy, Professor of Nutrition and Endocrinologist-Diabetologist at Lyon 1 University and Lyon South Hospital, Hospices Civils de Lyon (France). Cyrielle is an expert in the clinical care of metabolic disease, including type 2 diabetes, obesity and NAFLD, and is leading a clinical and research program focused on metabolic liver disease at the Lyon Hepatology Institute.

This conversation starts with Louise’s question around how patients respond when informed of liver-related conditions in the endocrinology clinic setting. Cyrielle shares a positive anecdote where a patient with obesity and Type-2 diabetes ultimately managed to improve weight in striving for a healthier liver status. For many patients, the notion that improving liver health will holistically improve their overall condition is a powerful and resonating source of motivation. Jörn notes this sort of positive relationship around biofeedback to be a recurring subject on the podcast. From here, Louise steers conversation to consider Cyrielle’s Paris NASH presentation which investigates how different phenotypes for chronic kidney patients may imply elevated risk of NAFLD and NASH. After elaborating briefly on this note, Cyrielle concludes with a powerful takeaway: “classifying your patient based on the presence of NAFLD or not is also classifying your patient regarding the prognosis of diabetes and not only the prognosis of liver.” As the session winds down, Jörn adds fascinating thoughts around the mechanisms and relationship between staging of liver disease, fibrogenesis and the metabolic drive that concerns the kidneys in parallel.

If you enjoy the episode, have questions or interest around endocrinology and Fatty Liver disease, we kindly ask that you submit reviews wherever you download the discourse. Alternatively, you can write to us directly at [email protected].

Stay Safe and Surf On!

Send us Fan Mail

As part of our ongoing dialogue around clinical care pathways and the complex of metabolic diseases, SurfingNASH dedicates a session to focus on the key relationship and interplay between endocrinology and hepatology. This topic rings familiar in the Rising Tide series, our podcast for frontline education, where Ken Cusi often notes the need for endocrinologists to become comfortable diagnosing Fatty Liver disease (and prescribing pioglitazone) and for hepatologists to become more comfortable prescribing GLP-1s. To expand on these critical ideas with the SurfingNASH community, Jörn Schattenberg, Louise Campbell and Roger Green are joined by Cyrielle Caussy, Professor of Nutrition and Endocrinologist-Diabetologist at Lyon 1 University and Lyon South Hospital, Hospices Civils de Lyon (France). Cyrielle is an expert in the clinical care of metabolic disease, including type 2 diabetes, obesity and NAFLD, and is leading a clinical and research program focused on metabolic liver disease at the Lyon Hepatology Institute.

This conversation begins with Roger’s note that around 50% of all cirrhosis is diagnosed for the first time during a decompensation event at the emergency department. He asks whether the endocrinology clinic is the right place to identify patients much sooner. Jörn suggests the answer is yes considering that we know the risk and prevalence of advanced fibrosis in this population to be high. The group goes on to discuss requesting and receiving lab results in their respective different systems and how hitching a test, like FIB-4, to routine care protocols could be an effective route for implementation. Cyrielle suggests that “the most important thing is convincing the endocrinologists” of NAFLD/NASH prevalence and our concerted ability to identify disease and stop progression at their clinics. She goes on to highlight the building momentum and consensus of guidelines from a range of different fields and organizations that formally recognize the relevance of Fatty Liver and the adoption of FIB-4 as a simple and cheap frontline test. She points out that In the most recent wave of published guidelines, there is a notedly improved sense of clarity in recommendations around how to identify and respond to patients with NAFLD/NASH.

Roger raises the point that the US might be one of the only countries, if not the only, that includes ALT values on blood panels. He asks Cyrielle what the process looks like in France for requesting ALT values to which she describes a relatively simple set of protocols. Jörn next describes his experiences within the German system. As the conversation winds down, discussion focuses on patient management and the importance of risk stratification in identifying those with more severe progression of disease.

If you enjoy the episode, have questions or interest around endocrinology and Fatty Liver disease, we kindly ask that you submit reviews wherever you download the discourse. Alternatively, you can write to us directly at [email protected].

Stay Safe and Surf On!

Send us Fan Mail

As part of our ongoing dialogue around clinical care pathways and the complex of metabolic diseases, SurfingNASH dedicates a session to focus on the key relationship and interplay between endocrinology and hepatology. This topic rings familiar in the Rising Tide series, our podcast for frontline education, where Ken Cusi often notes the need for endocrinologists to become comfortable diagnosing Fatty Liver disease (and prescribing pioglitazone) and for hepatologists to become more comfortable prescribing GLP-1s. To expand on these critical ideas with the SurfingNASH community, Jörn Schattenberg, Louise Campbell and Roger Green are joined by Cyrielle Caussy, Professor of Nutrition and Endocrinologist-Diabetologist at Lyon 1 University and Lyon South Hospital, Hospices Civils de Lyon (France). Cyrielle is an expert in the clinical care of metabolic disease, including type 2 diabetes, obesity and NAFLD, and is leading a clinical and research program focused on metabolic liver disease at the Lyon Hepatology Institute.

New to the podcast, Cyrielle takes a moment to outline her career trajectory and how she became interested in Fatty Liver disease and its growing area of overlap within the wider scope of medical care. From here, Roger describes overarching questions that the episode aims to cover:

• What does the interaction between endocrinologists and hepatologists look like from their relative perspectives? 
• In practical terms, how does each approach care pathways, referrals and collaboration? 
• What about either speciality would be key for the other to learn more about, develop and integrate?

Jörn first comments on the value of deploying the NITs developed by the hepatology community to endocrinology clinics. He notes the practical barriers which could hinder uptake and utilization as many may have lingering questions. How will this make a difference in the management of my patient? How do I potentially deal with a positive test? Do I need to refer this patient and what if I have nobody to refer to? Jörn looks to Cyrielle for advice on how to entice endocrinologists to align with the need of identifying Fatty Liver disease in their at-risk populations. Among other insights, Cyrielle underscores the importance behind raising awareness with endocrinologist colleagues that patients in routine screening are regularly diagnosed with advanced fibrosis and cirrhosis in the absence of symptoms.

If you enjoy the episode, have questions or interest around endocrinology and Fatty Liver disease, we kindly ask that you submit reviews wherever you download the discourse. Alternatively, you can write to us directly at [email protected].

Stay Safe and Surf On!

Send us Fan Mail

As part of our ongoing dialogue around clinical care pathways and the complex of metabolic diseases, SurfingNASH dedicates a session to focus on the key relationship and interplay between endocrinology and hepatology. This topic rings familiar in the Rising Tide series, our podcast for frontline education, where Ken Cusi often notes the need for endocrinologists to become comfortable diagnosing Fatty Liver disease (and prescribing pioglitazone) and for hepatologists to become more comfortable prescribing GLP-1s. To expand on these critical ideas with the SurfingNASH community, Jörn Schattenberg, Louise Campbell and Roger Green are joined by Cyrielle Caussy, Professor of Nutrition and Endocrinologist-Diabetologist at Lyon 1 University and Lyon South Hospital, Hospices Civils de Lyon (France). Cyrielle is an expert in the clinical care of metabolic disease, including type 2 diabetes, obesity and NAFLD, and she is leading a clinical and research program focused on metabolic liver disease at the Lyon Hepatology Institute. 

02:14 Introducing Cyrielle Caussy and Her Professional Background
New to the podcast, Cyrielle takes a moment to outline her career trajectory and how she became interested in Fatty Liver disease and its growing area of overlap within the wider scope of medical care.

08:42 Educating Endocrinologists on the Power of NITs Developed in Hepatology
From here, Roger describes overarching questions that the episode aims to cover:

• What does the interaction between endocrinologists and hepatologists look like from their relative perspectives? 
• In practical terms, how does each approach care pathways, referrals and collaboration? 
• What about either speciality would be key for the other to learn more about, develop and integrate? 

Jörn comments on the value of deploying the NITs developed by the hepatology community to endocrinology clinics. He notes the practical barriers which could hinder uptake and utilization. Among other insights, Cyrielle underscores the importance behind raising awareness among our endocrinology colleagues that patients in routine screening are regularly diagnosed with advanced fibrosis and cirrhosis in the absence of symptoms.

14:32 The Importance of Early Identification in At-Risk Populations and Implementing Guidelines

Roger notes that around 50% of all cirrhosis is diagnosed for the first time during a decompensation event at the emergency department. He asks whether the endocrinology clinic is the right place to identify patients much sooner. Jörn suggests the answer is yes considering that we know the risk and prevalence of advanced fibrosis in this population to be high. The group goes on to discuss requesting and receiving lab results in their respective different systems.

25:55 Discussing the Patient Perspective in Endocrinology Clinics
Louise asks how do patients respond when informed of fibrosis or other liver related conditions in the endocrinology clinic setting.

33:40 Biomarkers, Holistic Metabolic Assessment and Pathways
The groups discusses takeaways from various studies on the interrelatedness of  concurrent metabolic conditions and the influence of liver health.

40:57 Calling All Parties to Invest in Fighting Fatty Liver

If you enjoy the episode, have questions or interest around endocrinology and Fatty Liver disease, we kindly ask that you submit reviews wherever you download the discourse. Alternatively, you can write to us directly at [email protected].

Stay Safe and Surf On!

Send us Fan Mail

Surfing the NASH Tsunami celebrates its 3rd anniversary since the debut episode posted on April 15, 2020. The Big Band of Stephen Harrison, Jörn Schattenberg, Louise Campbell and Roger Green get together to reflect on key moments from the podcast’s history as well as predict milestones that will make the highlights in a 6th anniversary special three years into the future.

This final conversation starts with Roger recalling his forecasting roots. He agrees with Stephen that the more we learn about the role the liver plays in the constellation of metabolic disease and other causes of death, the more these diseases will fold back on themselves to create a richly textured understanding of how to treat the holistic patient at both the primary care and specialty level. This idea leads Louise to come back to one of her primary points throughout the podcast. She asserts that poor liver health is the problem and improving it early in life is pivotal. She goes as far as to describe the liver as the primary target for improving society's health and also to save money because improved health leads to lower demand for expensive medications and procedures.

The final question asks the group to consider what will be discussed on the sixth anniversary of Surfing the NASH Tsunami in 2026. Jörn discusses the increased use of treatment pathways. Stephen makes a statement he considers controversial, suggesting that only obeticholic acid and resmetirom will be approved by 2026. He goes on to discuss what this would mean in terms of care strategies and why advances in NITs will become even more important. As the session winds down, Roger asks Stephen to offer the last word of the day in which he replies, Promise. Tune in to the conversation for a special birthday surprise at the end.

If you enjoy the special, have questions or interest around Fatty Liver disease, please let us know your ideas by writing to [email protected] and leaving a review wherever you download the discourse.

Stay Safe and Surf On!

Send us Fan Mail

Surfing the NASH Tsunami celebrates its 3rd anniversary since the debut episode posted on April 15, 2020. The Big Band of Stephen Harrison, Jörn Schattenberg, Louise Campbell and Roger Green get together to reflect on key moments from the podcast’s history as well as predict milestones that will make the highlights in a 6th anniversary special three years into the future.

This conversation begins with Louise's perspective on what has played out to be either expected or unexpected in the liver space over the last three years. While aligned with the preceding responses of Stephen and Jörn, Louise raises her disappointment with the absence of an OCA approval from the FDA. She notes her belief that this experience has an important and positive influence on today's drug development landscape. In example, Louise points to increasing patient participation in clinical trials and improvements in trial design as positive major events. She then shifts to discuss nurse and allied provider education as a critical area experiencing growth. Her emphasis is on driving this trend forward given that these frontline professionals will be pivotal providers in patient education support when therapies become available. 

The group goes on to consider Roger's comments around how much richer collective knowledge has become over the time we've been doing this podcast. Roger also shares some favorite phrases of the co-Surfers that emerged in the podcast Drinking Game. Later, Stephen comments on the importance of NASH drugs in the entire constellation of metabolic diseases as well as extrahepatic cancers and obesogenic cancers. Finally, Jörn suggests that treatment will start slowly when drugs are approved, and that we will learn over time how to most effectively use the available tools and therapies.

If you enjoy the special, have questions or interest around Fatty Liver disease, please let us know your ideas by writing to [email protected] and leaving a review wherever you download the discourse.

Stay Safe and Surf On!