MAFLD
Summary
TLDRIn this informative lecture, Dr. Julius discusses the prevalence and impact of metabolic dysfunction-associated fatty liver disease (formerly known as NAFLD), highlighting its association with obesity and metabolic syndrome. He emphasizes the importance of early diagnosis, lifestyle interventions, and the role of hepatoprotectors like Essential Phospholipids (EPL) in managing the condition. The talk also covers the significance of monitoring liver health through non-invasive tests and the potential benefits of high-dose EPL treatment based on recent studies.
Takeaways
- 📊 Non-alcoholic fatty liver disease (NAFLD), now often referred to as metabolic dysfunction-associated fatty liver disease (MAFLD), is the most prevalent liver disease globally, affecting around 2 billion people.
- 🌐 The prevalence of MAFLD is closely linked to the prevalence of metabolic syndrome, with a significant portion of the global population affected by both conditions.
- 📈 There is a strong correlation between obesity, hypertension, diabetes, and the presence of fatty liver disease, indicating the importance of metabolic factors in its development.
- 🧬 The term NAFLD has evolved to MAFLD to better reflect the condition's association with metabolic dysfunction and to avoid the stigmatization related to alcohol intake.
- 🔍 Diagnosis of MAFLD can be facilitated by using medical calculators or fibrosis scores, such as the FIB-4 index or NFS, to assess the presence and severity of liver fibrosis.
- 🏥 Management of MAFLD primarily involves lifestyle changes, including weight loss, exercise, and dietary modifications, to address the underlying metabolic issues.
- 💊 Pharmacological treatments for MAFLD are still under investigation, with some traditional herbal remedies and hypolipidemic agents showing potential benefits.
- 🛑 Bariatric surgery may be considered for obese individuals with MAFLD, but its safety and efficacy have not been fully established and should be evaluated on a case-by-case basis.
- 🛡️ Hepatoprotective agents, such as Essential Phospholipid (EPL), have shown promise in improving liver function and reducing steatosis and fibrosis in some studies.
- 📚 Regular monitoring of liver function tests and non-invasive assessments, such as ultrasound or fibrosis scans, is recommended for patients with MAFLD to track disease progression and treatment response.
- ⚠️ MAFLD is a significant health concern with increasing prevalence, and proactive liver care is crucial for managing this condition and its associated risks.
Q & A
What is the current term used for what was previously known as NAFLD?
-The current term is 'Metabolic Dysfunction Associated Fatty Liver Disease' (MFALD), which reflects a better understanding of the condition's association with metabolic syndrome.
What is the global prevalence of fatty liver disease according to the studies mentioned in the script?
-The global prevalence of fatty liver disease is around 2 billion people, making it the most prevalent liver disease in human history.
Why is fatty liver disease often associated with metabolic syndrome?
-Fatty liver disease is associated with metabolic syndrome because it is commonly found in patients with obesity, hypertension, and diabetes, which are all components of metabolic syndrome.
What is the recommended weight loss target for patients with fatty liver disease to improve steatosis?
-To improve steatosis, it is recommended that patients aim for a weight loss of 3 to 5% of their body weight.
What is the significance of the FIB4 score in managing fatty liver disease?
-The FIB4 score is used to assess the presence of fibrosis in the liver, which is important for determining the prognosis and management strategy for patients with fatty liver disease.
How often should patients with fatty liver disease have their condition monitored after diagnosis?
-Patients should have their condition monitored every 6 months, including liver function tests and, if necessary, a fibrosis scan.
What is the role of EPL (Essential Phospholipids) in the treatment of fatty liver disease?
-EPL is used as a hepatoprotective agent to help repair and regenerate damaged liver cells, restore liver function, and protect the liver from further damage.
What is the recommended dosage of EPL for the treatment of fatty liver disease?
-The recommended dosage is 1,800 mg per day, which has been shown in studies to improve liver function and histological features of the disease.
Is there any evidence that fatty liver disease is reversible?
-Yes, from steatosis to mild fibrosis, fatty liver disease is considered reversible, but once it progresses to cirrhosis, it becomes irreversible.
What is the impact of bariatric surgery on fatty liver disease?
-Bariatric surgery can be considered for eligible obese individuals with fatty liver disease, as it has shown improvements in insulin resistance, liver function tests, and histological features of the disease.
Is there a recommended age for starting EPL treatment for fatty liver disease?
-EPL treatment is generally recommended for patients 12 years old and above, with a dosage of 2 capsules, 3 times a day, totaling 1,800 mg.
Outlines
📚 Introduction to Nafld and Metabolic Syndrome
The speaker begins by addressing a minor technical issue and then dives into the topic of Nafld, now referred to as metabolic dysfunction-associated fatty liver disease (Mafld). They discuss the prevalence of this condition globally, highlighting its association with metabolic syndrome and the lack of awareness among the general population. The speaker emphasizes the importance of recognizing the connection between obesity, hypertension, and diabetes with fatty liver disease, noting that a significant portion of the population with metabolic syndrome also has fatty liver.
👶 Pediatric Nafld and Its Progression
This paragraph focuses on pediatric Nafld, detailing the risks and progression of the disease in children. It mentions the high cholesterol, triglycerides, and low HDL levels commonly found in affected children, along with the increased risk of hypertension. The speaker also discusses the progression to advanced fibrosis or cirrhosis and the higher likelihood of pediatric patients progressing to compensated cirrhosis compared to adults. The paragraph concludes with the impact of Nafld on mortality rates and the shift in the primary cause of liver failure from alcohol to Nafld in patients under 50.
🔍 Diagnosis and Evolution of Mafld Terminology
The speaker explains the diagnostic criteria for Mafld, which includes the presence of steatosis by ultrasound and metabolic risk abnormalities. They discuss the evolution of the term from Nafld to Mafld, reflecting a better understanding of the condition's association with metabolic syndrome. The paragraph also touches on the importance of considering other etiologies that might contribute to fatty liver disease and the shift from an exclusionary diagnosis to a more inclusive one based on positive criteria.
📈 Assessing Fibrosis and Risk in Mafld Patients
The paragraph discusses the importance of assessing fibrosis in Mafld patients to determine their risk level. It outlines the use of medical calculators and fibrosis scores to identify the presence of fibrosis. The speaker advises on the appropriate actions based on whether the patient is at low or high risk, including referrals to specialists and the consideration of liver biopsies in borderline cases.
🏃♂️ Non-Pharmacological Management of Mafld
This paragraph emphasizes the importance of non-pharmacological approaches in managing Mafld, primarily focusing on weight loss and exercise. The speaker sets specific targets for weight reduction to improve steatosis and histopathology features. They also mention the role of structured exercise and the potential benefits of bariatric surgery in eligible obese individuals with Mafld.
💊 Pharmacological Treatments for Mafld
The speaker outlines various pharmacological treatments for Mafld, including standard treatments for metabolic syndrome, traditional herbal medicine, and hypolipidemic agents. They highlight the role of antioxidants and the use of essential phospholipids (EPL) as hepatoprotectants. The paragraph discusses the mechanisms of action of these drugs and the evidence supporting their use, particularly the medium probability of improvement offered by EPL.
🧪 Clinical Studies on EPL Efficacy
This paragraph presents clinical studies that demonstrate the efficacy of EPL in treating Mafld. It details a study involving liver biopsies before and after EPL treatment, showing a decrease in fat and reversal of steatosis. Another study is mentioned, which used a high dose of EPL and showed improvements in ultrasound and fibrosis scan outcomes across different categories of patients.
🌐 Global Recognition of EPL in Mafld Treatment
The speaker discusses the global recognition of EPL as a component of Mafld treatment guidelines in various countries, including Russia, China, Latvia, and Poland. They contrast this with the US, where more studies are needed for EPL to be included in guidelines. The paragraph also covers the benefits of EPL, such as its high bioavailability, ability to improve liver function tests, and safety profile.
🛑 Current Status and Future of Mafld Treatment
In this concluding paragraph, the speaker summarizes the current status of Mafld as a prevalent condition associated with obesity and the importance of lifestyle interventions as the cornerstone of treatment. They mention the role of pharmacological treatments, particularly EPL, as an adjunct to lifestyle changes. The speaker also addresses questions about the reversibility of Mafld, the recommended duration for monitoring patients post-diagnosis, and the use of EPL in children.
🤰 Clarifications on EPL Use in Special Populations
The final paragraph addresses specific questions from the audience regarding the use of EPL in pregnant patients, for whom it is not recommended. The speaker also reiterates the recommended dosage of EPL based on recent studies and emphasizes the importance of following the evidence-based dosage for effective treatment outcomes.
Mindmap
Keywords
💡Nafal d / NAFLD
💡Metabolic Syndrome
💡EPL
💡Fibrosis
💡Cirrhosis
💡Hepatoprotectors
💡Muffin / MAFLD
💡Ultrasound
💡FibroScan
💡Bariatric Surgery
Highlights
Non-alcoholic fatty liver disease (NAFLD) is now termed metabolic dysfunction associated fatty liver disease (MAFLD), reflecting its association with metabolic syndrome.
The prevalence of NAFLD is around 2 billion globally, making it the most prevalent liver disease in human history.
25% of the global population has NAFLD, with a higher prevalence in some countries, indicating a significant health concern.
Childhood obesity and its associated health issues, such as high cholesterol and hypertension, are on the rise, increasing the risk of NAFLD in younger populations.
10 to 25% of obese children progress to advanced fibrosis or liver cirrhosis by their third and fourth decade of life, highlighting the severity of pediatric NAFLD.
Pediatric NAFLD is associated with a 136% increase in mortality in 20 years following diagnosis, emphasizing the need for early intervention.
NAFLD has overtaken alcohol and hepatitis B as the leading cause of liver failure in patients under 50, reflecting a shift in liver disease etiology.
The term NAFLD has evolved to MAFLD to better reflect the current understanding of the disease and its metabolic associations.
Diagnosis of MAFLD now includes criteria such as steatosis by ultrasound and metabolic risk abnormalities like increased waist circumference and hypertension.
Patients with MAFLD can also have other liver diseases like alcoholic hepatitis or hepatitis B, indicating the complexity of liver disease diagnoses.
The natural history of NAFLD/MAFLD includes progression from simple steatosis to steatohepatitis, fibrosis, and potentially cirrhosis.
Most patients with NAFLD die from metabolic syndrome complications rather than liver disease, highlighting the broader health implications.
Non-pharmacological approaches, such as weight loss and exercise, are the cornerstone of MAFLD treatment, aiming to reduce liver fat and improve metabolic health.
Pharmacological treatments for MAFLD include standard treatments for metabolic syndrome, traditional herbal remedies, and hepatoprotectives like Essential Phospholipids (EPL).
EPL has shown promise in improving liver function and reducing liver fat in studies, making it a potential adjunct treatment for MAFLD.
EPL works by incorporating into damaged liver cell membranes, stimulating liver cell regeneration and protecting from hepatotoxic compounds.
High doses of EPL (1800 mg daily) have been shown to be more effective in improving liver health compared to lower doses.
Transcripts
oh
I have no disclosure uh
uh Jovanna can you excuse me for a minute
I don't know a compassator and or earphones
sorry about that say it again
so
okay
I will go back to sharing my screen
so tonight I will be discussing with you uh
Nafal d and then I will discuss with you
the impact of the change of the temperature
from Nafal d now it is called uh
muffled or metabolic
dysfunction associated fatty liver disease
and then I'll uh
discuss the role of EPL in the management of Napoli
why does not fall qualify as a pandemic truly
in your practice
you will see it a lot of patients with fatty liver and
and then
now I will be teaching you how to deal with them
so as a proof novel this
the most prevalent liver disease is in human history
the prevalence is around 2 billion globally
uh it is largely unknown to the general population
because uh
despite the the the um
the many uh the
the even the global uh
public health community doesn't know that there's a
large uh
population with uh Nafaldi
I don't oh sorry
um
Joe Ben sorry
I have a troubled SA SA and Apal
lullaby
just slow down maybe I'll just maybe I'll just
check
it
out
sorry
there's really a large number of patients with
enough for the fatty liver
because it's
really associated with the metabolic syndrome
if you see how many of our patient has obesity
a hypertension
diabetes you will
you'll find out that if you do a autosound
actually they are fat liver
so actually more or less
the population with metabolic syndrome
is almost the same as the population with fat liver
so according to the studies done census in the US
they said that 25% of the global
is the global prevalence to be serving
one out of four person
so if you're sitting with somebody
one of you go upper cage
and one of you probably have body liver
so Asia it's lower it's 23.3
but some countries it's even higher up to 30% no
the the truth of the matter is because of obesity
of obesity you can see that maybe your seatmates
I'm sorry to tell to say that yeah
even myself is overweight so 1 out of 4 person is
has metabolic syndrome because of overweight
so this is also influenced by our how we eat
that's why childhood obesity is also becoming very high
it has rise for the past four years 10 times
and you know if a child has a fat delivery
it has increase in
the child is obese already during childhood
then when you check their
blood they would have a high cholesterol
high trigesrides
no HDL so that they have 20 to 30% of them um
is reported to be hypertensive already also uh
10 to 25% of them progress to
advanced fibrosis or liver serosis
by the third and fourth decade of life
that's why
pedratic novel patients are more likely
than adults to progress to the compensation
and also
because you can also see that obese children are
have high
high risk of developing diabetes
so that in
summary pediatric novel is associated with
1,360% increase in mortality in 20 years
following diagnosis
so that uh
you know that the liver transplant is the uh
ultimate uh treatment for liver failure
and you know before they were telling us that uh
alcohol was the most common cause of liver failure
but now uh for those patients less than 50 years old
the number one uh
cause of uh liver failure is already Nash
it has overtook uh liver
uh hepatitis B and also uh alcoholism
so really this is really
something that has evolved through the years
so that uh
they they came out to a term that uh
novel actually should be called muffin
before in our med school as you remember
uh we diagnosed napole by exclusion
so No. 1 if the patient doesn't drink alcohol
then if the patient has no viral hepatitis
or there's no ideology of hepatitis
uh other chology of hepatic status
then we'll say that uh
because uh you have you're not a drinker
so you're called nafall
or non alcoholic fatty libert disease
but into the years
they found out that the novel de patients
become some more that is prevalence increases
and they found out that actually
these non alcoholic fatty labor disease patients
most of them have metabolic syndrome
that is why they did because a lot of these
not for the patients are actually
have metabolic dysfunction
so they they now
change the term into metabolic
dysfunction associated fatty liver disease
which has this criteria
so if there's steatosis by ultrasound
plus one of the three
if the patient is overweight or obese
the patient is have diabetes
and at least two of the risks are abnormalities
metabolic risk abnormalities
which is a increase our weight circumference
uh hypertension high triglycerides
low HDL
prediabetic insulin resistance and increase in CRP
so because of this uh malfo then uh
it's easy to understand that uh
actually we don't use math
NAFOL or non alcoholic party liber disease anymore
but we use the metabolic sing
metabolic dysfunction associated fatty liver disease
with this then we can have
a patient can have a MFLD
and also I alcoholic fat deliver
and also have a chronic hepatitis
B hepatitis so then you
a person can have 2 or 3 causes of fat liver
so because of that diagnostic idea
to better reflect the current knowledge of
to capture the full spectrum of the deceased
now we know that novel dee allies actually maffody
now we know that uh because of this term
now we start to look for metabolic syndrome
in connection with fatty liver
it simplifies the diagnostic process
by using a positive criteria
rather than by an exclusionary process established
a conceptual framework grounded on science
considers
other geology that might contribute to fatty liver
that was I saying to you
that a person may have a fatty liver
may also have alcoholic hepatitis
may also have hepatitis B infection
a better disease
subtyping a little precision of medicine
now we know how to treat this
because we know this is associated with fatten uh
of uh associated with metabolic syndrome
so the new nepectors should convince the stigma
stigmatization of alcoholic intake
so now we know
so so that just to show you the natural history of
of not fall
now on the left side you see a normal reliever
then if if the patient becomes fat
then there will be
is theatosis or fat infiltration inside and the liver
no no
a lot of them later on
because of that fat will cause inflammation
so the inflammation
we call it inflammation of the liver or hepatitis
so we call now if there's inflammation
we call this a non alcoholic uh steato hepatitis
then because of that hepatitis
that chronic inflammation patients uh
or only immune system will heal
and take care of the inflammation
which produces fibrosis in return
so if there's a lot of fibrosis
because of a prolonged process of repair
repairing the the hepatitis
the inflammation
then at the end one will have liver cirrhosis
well one may also have uh docelocancide from
from histheatosis to mild fibrosis
there is five times increase in cardiovascular disease
actually most of our patients with Napoli die
not of the liver disease but they die of uh
the metabolic syndrome
and they have five times increase in risk of uh
uh car job events
while those patients who proceeds to become a cirotic
then that's a time that we see the
these patients die of
complications from liver diseases
so as you can see in this uh slide
this is uh uh
the sequential path of ecological state of novelty
and its progression
so on the top you can see that this is a not
there's novel which is a fatty liver
then going down there is a next step will be H
which is hepatitis because of the inflammation
and afterwards go down
then you will have fibrosis the more fibrosis
the more severe the patient will have will be no
and also the more risk um risk HCC risk
uh the more metabolic syndrome uh
uh items like a southern entire lifestyle obesity
insulin resistance
increase of age this also increase
the morbidity and mortality of liver disease
but then you will see that not all my faulty are uh
actually obese actually one of the uh there
one of more than six of 10 of patients with diabetes
nine out of 10 severely obese have not for the
but one out of four people have not for the
regardless of the weight
but then if you see the progression
and the characteristic and the implication of these uh
two uh subset of patients comparing the lean patients
lean enough old
and comparing them with the obese patients
actually they go on the same route
they go from uh
fat delivered and inflammation and fibrosis
but uh this uh this study shows that uh uh
the the the the pathway is the same
so we should treat those patients with lean and
and fat uh
fatty livers the same way
so uh let me tell you how to diagnose uh
fatty metabolic dysfunction
fatty liver disease so number one is
you know the
we did a ultrasound to a patient
and a patient comes to us with a
ultrasound of fatty liver and a high
sgpts with that what should we do now
now we can see on the left hand
left hand side it officially obese
which is uh if the BMI is more than 23
uh for Asians no then we can already
a fat deliver an ultrasound plus an overweight
a BMI of more than 23 then we can uh
confidently say
this patient has metabolic syndrome associated
fatty liver disease likewise on the right hand side
if the patient has fatty liver and ultrasound
then the patient is diabetes
then we that is the two
the criteria is also already says that are
makes us conclude that this is a metabolic dysfunction
associated body for deceased
but if the patient is lean
then you have to look for other
uh two metabolic
risk abnormalities to consider them to have mphd
so if the waste circumference is more than one
uh is more than 90 for Asians in men or 80 in women
so I hope you know the waistline
the waistline is not the belt line
the waistline is the the line above the umbilicals
is the narwest portion of our uh torso
now if uh in men it's 90 centimeter
so it's around if it's more than 35.5 centimeter
glycerides is more than 1:50
the L hdl is less than already diabetes
okay if the
if there's insulin resistance
and if there's a high CRP
there are two of these then you can consider them
plus a fatty liver and ultrasound
we can already consider them to have metabolic syndrome
associated fatty liver disease
now if you are presented with a patient
now you know that this patient has
the reason for their high sgbt is fat deliver
is metabolic in nature so what should we do now
we should next check for the fibrosis assessment
as you say as I said before
the fibrosis score is very important
because it tells us about the prognosis
so how do we do a fibrosis scoring
how do we know that the patient has fibrosis or not
then we can use the calculators
medical calculators using the V4 or the uh
NFS or fiber test there's a lot in our
you can just
use it in our phone or just request for a fiber scan
and a fiber scan will tell us if
the patient has fibrosis or not
now if there is no fibrosis
then the patient is considered to be low risk
if there's low risk
you don't have to refer to us other specialist
you just you know this patient the nature is metabolic
so just go ahead and treat the metabolic problem
and just repeat this non invasive test
every two to three years
but if the patient is high risk
which means the patient has fibrosis
and it's better to refer the patients to a gastro
because then we will be uh
looking for just the clinical uh
the clinical symptoms of liver cirrhosis
and treat them accordingly
because you know that if there's already cirrhosis
then we have to look for a viruses because
you know viruses is one of the
cause of mortality of these patients
we need to check for hypotocellar carcinoma
and if we need to do or check for
if the patient has a science of the compensation
the compensation like ascieties and encephalopathy
so we have to treat that according
now if if the patient is in the borderline
then the recommendation is to do liver biopsy
but then because a liver biopsy is uh
is difficult and it's uh invasive
and it is very difficult to convince a patient
just to see if there's fibrosis
we want to do a liver virus
so if you uh in in our case if we
if the patient is in the
in between fibrosis and the normal
so we will just go ahead and aggressively treat
the metabolic syndrome and likewise
screen patients for viruses or other
complications of liver disease
so just to tell you this is the
this is what I use in my clinic to
to check for fibrosis
so I usually use the FIB4 because it's the easiest
it consists only of four that's why it's FIB4
so you just need the age
the ASPLD and the platelet come so you can just always
you uh request for your regular blood chem
you just need to put in uh
the CBC platelet
because you need a platelet and the Alt and iced
if it's a less than 1.3 then it will solve fibrosis
if it's more than 3.25 it predicts fibrosis
you can just put it in your medical calculator
and your phone will do the
the calculation for you
or you can use the NAFL d fibrosis core
now with comprises of the HLD
SD platelet called BMI
albumine and impaired fasting glucose okay
so you can use this to test okay
so now that in the beginning
you have a patient who came into you with a fat liver
and ultrasound then you what will you do
you have to check for the fibrosis score
now if you know now the fibrosis score
now you know
if it is a low risk intermediate is a high risk now
now I will be telling you about how do we manage them
what do we keep so
so why do we treat because there's you know
there's a long term outcome of patients with maffody
and Nash
compared for the controlled population
of a metabolic syndrome is
if one has metabolic syndrome plus fatty liver
the increase
there's increase overall motority compared to the
those with no muscle and it processes risk for CBD
higher risk for CBD events
no uh
it poses greater risk for hypertension and diabetes
than diabetes alone so it also poses a risk for CKD
colorectal cancer
in the chronopathies and osteoporosis
so
just want to
not due to you
to know that
if you are doing a test for metabolic syndrome
please do include finding people with
also with ample d by by checking for the asdld
and the ultrasound of the liver
not only that uh why do we treat Malfo
because when
when the deceased progress it goes to become a
if there's a lot of fibrosis
then it it will produce a severe liver disease
which will later on uh go to cirrhosis and ACC
so uh
so that the the goal is from fibrosis we want them
why want to bring them down to steato
hepatitis and then going down to a hepatic steatosis
so these are the very important thing to do
which is the non pharmacological approach
because this is the core
this is the cornerstone of treatment
so we need to have a weight loss
we don't only tell patients to lose weight
we have to tell them
we should have a target weight loss uh
target weight loss
so uh if we want to improve statosis
we want to to reduce the the fat in the liver
we have to decrease the weight by 3 to 5%
but
and if you want to improve the histopathology features
such as you want to decrease fibrosis or the degree of
uh inflammation
then you need to decrease the weight to a 7 to 10%
so that it is very important to
emphasize on the target weight loss
not only just telling them to lose weight secondly
exercise exercise alone may prevent a reduces slatosis
but its ability to improve other aspects of
liver astrology needs further investigation
so when you tell them to exercise
need to tell them that it
they should have a structured exercise
or they should go to a
somebody who can help them in the gym
so they should exercise around uh 150 minutes
uh in a week so that means that maybe you can do a uh
two forty five minutes or
uh three forty five minutes or uh
I'm sorry 1:21
20 minutes per week so that you need to do a 40
40 minutes three times a week
so you can buy 40 minutes three times a week
or you can do swimming 40 40
40 minutes three times a week or you can do Zumba
40 minutes or three times a week
or one hour twice a week
so that is that is the cornerstone
so these two these two areas we should emphasize
now how about bariatic surgery
it can be considered in otherwise eligible
obese individual with my phone
it's the premature and to consider bariatic surgery
the type safety efficacy are not yet established
so that it's still difficult to
recommend a certain type of biotic surgery
and in patients we compensated
Nash or cryptogenic sclerosis
biotic surgery may be considered case to case basis
because it may cause more harm than good
so uh when do we recommend bariatric surgery
if the BMI is greater than 40
if if while if the BMI is more than 35
but plus obese obesity related comorbidities
the patient is hypertensive and BMI is more than 35
then we might uh
send them to uh for uh bariatric surgery
so
because a small
prospective studies has already showed that there's in
there's improve instrule resistance
liver function test
and it really improves the path of cerepathic
seposis and fibrosis no
but then it's a because there's no well designed
randomized control trial
and we cannot recommend what particular
bariatic surgery to do
also because our patients are wise
they weight there will be rate weight regain
because they will adjust their eating habits to the
to the size of their stomach
so that usually patients are regain their weight
so that's about uh non pharmacology and a bariatry
now we go to pharmacology
you have this four uh types of uh treatment or
or uh medical treatment
1 is a standard treatment for metabolic syndrome
which targets the
the um targets sugar fasting diabetes
so that my included on this area is metformin
people are setting mob DPP GLP
so we can use this if our patient has diabetes
then secondly is a traditional herbal
uh included in this list is uh automeric or uh
in a set of sustain okay
uh the other thing uh
I'm not uh really part uh familiar with and
and another is the hypotheprotectives which we use for
for the longest time we use EPS in the marine vodka
vitamin B um dotation same
and uh there are new things that uh
on the block
that still investigatory of betacolic acid uh
and so on so because uh
there's inconsistent evidence for standard medication
using comorbid conditions is not for uh
traditional agents uh
while the traditional agents are
lack supportive research
the only thing we can give
at this moment are the hypata protectives
it is it remains to be important
reliable part of our treatment
so you can see that uh
on the left left hand side this
the mechanism of this all this uh gamut of drugs
so No. 1 on the left hand side
we want to decrease the free fatty acid in our body
so we so on the left hand side is diet
exercise and weight loss or weight
or drug that induce weight loss
well uh
we can also give uh uh
antioxidants because we want to target the oxidative uh
stress uh
this includes a vitamin E
eps limarine
uh their mode of action is uh towards uh
uh be having antioxidants
uh and then uh lower down is uh
they say that uh bacterial translocation also uh
is have a role in this in in national
some are already advocating uh
the use of probiotics on a higher up
you can see that on the right hand side
that insulin synthesizers
metformin and the other side is also the antioxidants
so just to tell you of all this
this
these drugs on the market
you can see that on the vertical line
you can see that level of existing scientific evidence
low from below is low medium high
very high you can see where EPL stands
it stands on the middle medium existing evidence
while others like Silly Marine is on the low side
well if you see on the horizontal
uh lack of improvement low probability
medium probability high probability of improvement
or very high probability you can also see that uh
EPL is on the medium probability
compared to other medication suites
they did not have they were not able to prove their uh
their drug to be uh improve
uh in a randomized control
randomized control trial to be uh effective no
so uh what is the medical mechanism of action of EPL
so it it
incorporation of EPL
into the damage membrane of the liver cells
so that it uh
helps in the restructuring of the damaged membrane
it increased the cell membrane fluidity
it increased transmembrane exchange in
stimulate liver cell regeneration
that's why it uh it uh
reinstate metabolis metabolism
and then enzymatic process to restore and maintain
liver function
it stimulates regeneration of the liver cells so that
to restore and maintain liver integrity
and likewise it protects from hepatotoxic compounds
the restoral maintain liver resilient
so this is the main uh uh
motive action of this disease
as this is a very important study
it involves the liver biopsy
because who wants to have a liver biopsy
because before they need to uh
do a liver biopsy
so that they will be able to document
if the fibrosis has improved or not
so this study
comprise of 30 patients with histologic proven
fatty liver disease who are diabetic and
but HBS negative or not hepatitis B patients
so these patients the the first
document that they have
fatty liver by doing liver biopsy
and then they give 1,800
milligram per day for 6 months of BPL
after which they do another biopsy
and you and it shows that the
the esthetos is the amount of fat actually decrease
um there's a reversal of stenosis when you give EPL
in this study
so uh this is another studies
uh Central Force Philippines
a supportive adjunct management of uh
patients with now for the
this is uh I think uh
very very recent
this is uh 19 uh
this is 2,015 uh
this uh
they they group the patients with navaldy alone
navaldy with diabetes navaldy with dyslepidemia
and then they give uh the regular uh
standard diet and physical
of the activity of 30 minutes walking
5 times per week
and they give a high dose of EPL
of 1,800 of BPL daily for 24 weeks
and then they bring it down to 900 for the
for another 48 weeks and they
they check for the outcomes
which is the aotsd ultrasound and fibrous fibrosis scan
so in all in all category
you can see that there's improvement
whether it's belong novelty
diabetic novelty disability big novelty
when they check the ultrasound
they see that the fat infiltation decreased no
in overall at a at a at a rate of 29 point
okay so
our EPL is an essential component of all cellular
subcellar membranes
that's why it incorporates to our liver cells
that's why it helps in healing
so the mode of action is
actually helps in the repair or regeneration of damage
liver cells
and uh it is very uh
highly uh bioavailable
it's 90% absorb in our body
uh compared to silly marine and uh uh same
uh it was proven to decrease altsd and GGT
it is uh it was able to improve the lipid profile
it was able to improve the stenosis and fibrosis
it was also able to improve the
as an adjunct to to diabetes treatment is
improves the clinical outcomes
and also it was able to prove that histologically
it was able to decrease stenosis
and you can take it with or without meals okay
it is safe
it is no drug
drug interaction compared to Silly Marine and others
so because of that our EPL is already included in the
in the many guidelines in the
in the guidelines of enough of the
in other countries such as in Russia
in China in Latvia and Poland
so they are already included in their guidelines
but for us and us uh
it's still not yet uh uh
they
the USD still has to
needed more studies for them to be
convinced that EPL really works
but then in other countries
they already included their guidance
so uh currently
there is no stop this pharmacological treatment
uh but evidence shows that positive effect of back
autoprotectants maintaining lose
maintaining weight loss of 5 to 10% is important
to improve astology
moderate physical activity
moderate physical exercise improves
markers of insuring uh
sensitivity in my phone
that's why it also it helps in improvement of uh
fatty liver uh
colalic
caloric restriction is the main driver for weight loss
and these are all adposities of cutaneous fat
and liver fat reduction so um
so in summary muffal is a pre existing pandemic
even as we don't know that
because of it is highly associated with obesity
muffal continues to increase in prevalence
and worse during Covid because of people were inactive
lifestyle event
intervention
remains the cornerstone of the treatment of my faulty
which is to eat less to lose weight to exercise
then also in our part we can then give an adjum
if you want to give an adjum
if the patient can afford them
please do choose a medicine that has studies like EPL
which has a little
I've shown you all the studies that
they were able to do
so with that
I want to thank you for your kind attention
I would be glad to answer any questions
thank you thank you very much
Doctor Julius sir
sorry I know for the very competitive lecture
okay let's proceed with our some of the questions here
uh prepared by our colleagues
okay a first thing to ask our question
doctor is the very common is uh
a segregational of his specialist uh
is partially reversible
no uh
they say it's fat it
it can so fat deliver
there's a spectrum right
there's a fat deliver
then uh
so there's a fat liver then if you have a fat liver
then you will have uh
inflammation and there's a fibrosis and there
and then you go to the extreme cirrhosis
from fat liver stenosis to mild fibrosis
it is reversible
but onwards it is irreversible
okay that's a very clear
thank you very much doctor for your kind insight
doctors do you have any question regarding the election
if you want some clarification regarding the
new name and picture on
the metabolic association with disease
and its management so yeah yeah stop that
I'm going to ask them what is
how many months from first diagnosis of my phone
what did the management
did you hear that doctor
how many months how many months
how many months do hold on let me just use the mic
good
evening
abdominal ultrasound doctor
how many months should they uh
contact with after 5 days
uh that after diagnosing it
oh then um
um patterned on the status
if the management was effective or not yes
the pattern to the studies uh
they usually do the repeat uh
monitoring of the not only the the ultrasound
but also the uh
liver function test liver every 6 months
but every 6 months yeah
but but um
uh we don't do uh
ultrasound as a guide to see improvement okay
so the
the the parameter to say that there's improvement
it's actually is the loss of inflammation
so sgbt and a L t s g o
t is the parameter that tells us that
there's inflammation if the if the liver is inflamed
the sgbt will go high so once you treat with EPL
you want to know if you have already
if you have controlled the information
so the test to be
the test that should be done is actually SGPT and SGOT
now if you want to know if there's
there is a reversal of stentosis
like what I'm telling you from fibrosis
if there's a reversal of from mild fibrosis
it become uh
uh stenosis right
or no fibrosis so you have to request for a fiber scan
no fiber scan is a
it's a kind of special ultrasound which can uh uh
actually uh
it's a it's a astography which means that it
it does
sends a autosound signal to relieve liver cells
and it goes back to the to the to the receiver
then if the the if the liver is stiff now it's hard
then you will have a
then the fibrosis score will be high
but if there's a low so there will be no fibrosis
so that if you want to know if the
if there's reversal in this histologic features
then you have to request for a fiber scan
and I do fiber scan every year
okay that's good doctor
that this is available here in Beagle
is that correct yes okay
yeah
it's available
I have a question here
doctor from our from the chat box okay
coming from okay good evening doctor
thank you doctor for the very good lecture
question lamp
what is the recommended age to take essentially
thank you very much
uh I'm not particular with uh
don't know about uh really pediatic patients but uh
I usually give uh
EPL when the when the patient is heavy enough
like if there are big kids like uh
uh 50 kilos above yeah
but then I
I'm not sure job it maybe you can help it out
yeah me
help me out with information
in terms of the judic doses here
based on the patient information detailed
and then as we also recommend
the age starts from 12 years old in a Bob
so we have no studies that should be taken 11 years old
middle so as recommended
12 years old and above to be taken 2 capsule
3 times a day
so total of 1,800 mg
any more questions for a clarification
about what
and something that bothers you about mouthful
hypothe protectors management
okay doctor the question is
they recommended dosages to capsule three times a day
or total of 1,800 mg the question is doctor
if uh can they lower the dose
from one template or one capsule or two capsule per day
so based on your recommendation
and make sure that that's
what is your comment on this
yeah thank you for that question because uh
you can see that uh because of
because essentially has been
or EPL has been there for a long time now um
and then it be actually in a while
it became a over the counter medicine right
so that them it is actually given as a
as a non therapical
you can just give once a day or twice a day
but then because of that before
they were not able to see a significant improvement
with that low dose
uh
with regards to a L t with regards to astology now uh
now they're advocating a high dose because they
they found out that if you give a high dose
then there's really improvement
so maybe the
those that were using before is not high enough
that's why the studies were not really that good
the the results of the studies were not good
but now 2,015 2,020
all these studies are using 1,800 milligram EPL
and they and they show these results
so you know uh
because of that uh
I cannot recommend to have the same result
if you have a if you gave a
if you give a lesser dose because that is a
this is according to the studies
our recommendation is according to the Statistan
okay the player
I have a question here from the chat boss area
how about study regarding pregnant patients
well okay
she go to the doctor I can answer that for you so
okay so basically based on again
from the patiently
that it is not recommended for pregnant women
so just to be sure just to be
any more question doctor
I hope I was able to to answer clearly the questions
yeah if you have follow up questions please do so
you can reach Doctor Julius in Naga
so are you okay now doctor
okay
I think I was
I think doctor
that is the last question that from the group
and thank you very much doctor for reaching out for us
and at this point of time
thank you doctor for increasing this location
and give this a chance to show to us
the effectiveness of hepathoprotectors
in treating metabolic associative fatabilities
and the importance of pro active liver care
again Doctor Julius
thank you very much hope to see you soon
our future activities enjoy your dinner
we're having dinner here okay
thank you thank you for kind
let's hear our Territory Manager for that here
um good evening doctors again
uh internet
first I would like to thank our doctor
Doctor Julius sponsor Yana
for giving his invaluable sign to share his experience
it's been an honor
and privilege to have you as our speaker
second I would like to thank all the doctors
who participated in our IPD
and it's been a pleasure for giving us the opportunity
to to be part of your CMP activities
on behalf of Professional Insights
Marketing Services
Incorporated and Sandalpi Consumer Healthcare
we are indigrateful to the doctors of Saug
this is done together with our MCE surgeon Jonas
and Sir James
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