THE OFFICIAL NEWS SOURCE OF ACR CONVERGENCE 2022 • NOVEMBER 10-14



NAFLD becomes a growing concern in rheumatology

Danielle Brandman, MD
Danielle Brandman, MD

Nonalcoholic fatty liver disease (NAFLD) is not high on the list of concerns for many rheumatologists, but it should be. NAFLD is approaching epidemic proportions in the United States, and some of the most commonly used rheumatologic agents can cause or contribute to the worsening of liver disease.


“Fatty liver disease potentially affects up to a third of the U.S. population, but it may not be a primary focus for many rheumatologists,” said hepatologist and liver transplantation specialist Danielle Brandman, MD, Associate Professor of Medicine at the University of California, San Francisco. “The conditions that are most often associated with fatty liver are obesity, hypertension, diabetes, and hyperlipidemia. Given that about two-thirds of the U.S. population is either overweight or obese, it’s not really surprising that we’re seeing this epidemic of fatty liver.”


Dr. Brandman will discuss the connection between rheumatology and NAFLD during NAFLD & Hepatotoxic Medications: What’s a Rheumatologist to Do? on Tuesday from 1:00 – 2:00 pm in Room B405-B407, Building B of the Georgia World Congress Center. Rheumatologists may not be able to change the lifestyle and environmental factors that contribute to the rising incidence of fatty liver disease, but they can adjust prescribing practices to reduce the likelihood of drug-induced liver disease or contributing to existing liver problems.


Psoriasis is associated with an elevated risk for fatty liver, Dr. Brandman noted, but rheumatologists should at least consider the potential for liver injury in all of their patients. Excessive acetaminophen use and antimicrobial agents are most commonly associated with liver damage, but rheumatologic agents also are high on the list of problem drugs. 


Methotrexate can cause direct liver injury, particularly in high-dose or long-term use. Prednisone and methotrexate can also exacerbate underlying fatty liver and other liver diseases. Among NSAIDs, diclofenac and celecoxib are most often cited for their potential for liver injury. Infliximab has been associated with liver injury. 


The potential to cause liver damage or exacerbate existing liver disease does not mean that rheumatologists should abandon these agents, Dr. Brandman said. All are used for good reasons. 


Prednisone and methotrexate may carry potential for hepatic injury. So while they are highly effective, affordable, and broadly accessible for many, they should not be the automatic choices for all patients.


“There are other, newer drugs that are potentially safer for the liver,” Dr. Brandman said. “What drug to use is a case-by-case, patient-by-patient decision. It is always about risks and benefits for the individual patient. Hepatotoxicity is one element to include in that decision.”


Specialists and primary care providers alike are gaining awareness of the risk that nonalcoholic fatty liver disease poses but may need assistance in assessing risk of hepatoxicity of a variety of medications, particularly in those with advanced liver disease. 


For rheumatology patients who already have advanced liver disease, prednisone and methotrexate may not be the most appropriate drug choices. For other patients, it’s more a matter of recognizing the potential for liver damage and monitoring liver function on a regular basis.


“Just because a drug may carry a risk of hepatotoxicity does not mean that your patient will experience it,” Dr. Brandman said. “There is the question of at what severity of liver disease and rheumatologic disease does it become appropriate to stop a risky medication and choose an alternative? Because fatty liver disease is so common, with potential for some patients having advanced disease, rheumatologists cannot ignore the very real potential for fatty liver disease in their patients.”