NAFLD & NASH in the Hospitalized Patient: The Hospitalist’s Guide to Fibrosis Triage, Comorbidity Control, and Advanced Management

In this episode of Hospital Medicine Unplugged, we tackle NAFLD—screen smart, stage fibrosis fast, and treat the heart to save the liver.

We open with the do-firsts: targeted case-finding, not blanket screening. Prioritize patients with obesity, T2D, metabolic syndrome. Start with FIB-4 (age/AST/ALT/platelets): <1.3 (or <2.0 if >65) = low risk; 1.3–2.67 = indeterminate; >2.67 = high risk. For indeterminate/high, add elastography (VCTE/MRE). Reserve biopsy for discordant NITs or when confirming NASH/advanced fibrosis will change management. Flag that acute illness skews labs—repeat FIB-4 after discharge if values were “hot.”

Lifestyle is the therapy with the biggest effect size: • Weight loss targets: ≥5% improves steatosis; ≥7–10% improves NASH/fibrosis. • How: Mediterranean-style diet, energy deficit, and structured exercise (150–300 min/wk moderate or 75–150 vigorous; practical: 2–3 aerobic sessions/wk at ~65–75% max HR). • Even without large weight loss, more activity drops ALT and liver fat. • Alcohol: restrict—even moderate intake can worsen injury.

Med & procedure lane (select patients): • Pioglitazone 30–45 mg daily for biopsy-proven NASH (esp. with T2D)—counsel on weight gain/edema/fracture risk. • Vitamin E 800 IU daily only in non-diabetic adults with biopsy-proven NASH—discuss risks. • No broadly approved “NASH drugs” yet; many agents in trials. • Bariatric surgery (right candidates): large, durable weight loss with frequent NASH resolution and fibrosis regression.

Treat what actually kills: the cardiometabolic bundle. • T2D: optimize; GLP-1 RA / SGLT2i favored for weight/CV/renal benefits (NAFLD-friendly, even if not NASH-approved). • Lipids: statins are safe across NAFLD (including compensated cirrhosis)—use them. • BP & OSA: control aggressively; screen for sleep apnea.

Monitoring & follow-up: • Track fibrosis, not just ALT. Re-check FIB-4 periodically; repeat elastography as risk evolves. • Once cirrhosis (or advanced fibrosis per local policy): HCC surveillance q6 mo, manage varices per guidelines. • Vaccinate (HAV/HBV), reinforce adequate protein, and set realistic weight-loss trajectories (≈0.5–1 lb/week).

Hospital-specific pearls: • Use admission to risk-stratify and place outpatient elastography—don’t overcall staging on transient in-hospital labs. • Med rec: stop hepatotoxins where possible; (re)start statin if indicated; align diabetes regimen toward GLP-1/SGLT2 when appropriate. • Document alcohol use and offer brief intervention + supports. • Loop in nutrition early to avoid sarcopenia, especially if decompensated.

We close with the system moves: a NAFLD bundle that (1) auto-calculates FIB-4 in the EHR; (2) orders elastography for FIB-4 ≥1.3 or any T2D with risk factors; (3) triggers hepatology e-consult for FIB-4 >2.67, high stiffness, or discordant NITs; (4) defaults a lifestyle pathway (dietitian + exercise referral + written 7–10% weight-loss plan); (5) nudges cardiometabolic optimization (statin-on unless contraindicated; GLP-1/SGLT2 suggestions for T2D); (6) adds an alcohol counseling tile; (7) sets surveillance reminders if advanced fibrosis/cirrhosis; (8) hands the patient a one-page Mediterranean diet + activity roadmap.

Fibrosis sets the prognosis; lifestyle moves the needle; cardiometabolic control saves lives—NAFLD care that’s measurable on the wards and durable after discharge.