The reality of modern life is fatty liver. Treatment and diet. Causes of fatty hepatosis

Sergey Nikolaevich Maltsev

Gastroenterologist, therapist. Professional experience: 12 years

Lipids accumulate in the liver as a result of alcohol abuse, poor diet and physical inactivity.

The diagnosis is confirmed if the fatty part makes up 10% or more of the total liver mass. The deposits are predominantly located in the 3rd and 2nd hepatic lobes.

In the absence of therapy and diet, with obesity, alcohol abuse, hepatosis is dangerous due to the following complications:

• low-grade inflammation;
• cirrhosis of the liver;
• malignant formation.

At stages 1-2, a long-term diet will help remove body fat and return the organ to its previous performance, but the advanced form requires a strict and constant regime, which concerns not only nutrition, but also lifestyle in general.

If there are signs of the disease, you must contact a medical facility for examination. To confirm hepatosis and determine its degree of development, it is necessary to use the following diagnostic methods:

1. Consultation with a gastroenterologist (history collection, palpation);
2. Ultrasound diagnostics (ultrasound);
3. Angiography;
4. Magnetic resonance imaging (MRI);
5. Laboratory analysis of liver enzymes.

After examining the patient, a course of therapy is drawn up aimed at detoxification, organ regeneration, correction of metabolic processes and elimination of risk factors. The basis of the course of treatment is a strict diet that must be followed for a long time.

Medicines that can overcome the disease without adjusting the diet, does not exist, but some drugs are used as a supplement and maintenance therapy for diet.

Diet for fatty hepatosis

A special diet has been developed for patients with fatty hepatosis - one of Pevzner’s 15 therapeutic diets.

The developed diet allows you to avoid oversaturation of the body with fats, but at the same time satisfy all the requirements of a person leading an active lifestyle.

Diet No. 5 helps to reduce overall body weight - in 30 days it is possible to lose about 5 kg of weight. A slow pace of weight loss is the least stressful and allows you to maintain the results for a long time.

Allowed foods (diet No. 5 according to Pevzner):

1. Lean meat (without films, tendons, cartilage). Use chopped or whole;
2. Offal. From this category only language is possible;
3. Poultry - turkey, chicken, but with skin and fat previously removed;
4. Fish - low-fat varieties (sea bass, cod, pike perch). Black caviar and soaked herring are allowed in limited quantities;
5. Pastries, bread - dried (yesterday's) rye and wheat, savory pastries, dry cookies and biscuits. This category of food should be limited if the patient is obese;
6. Chicken eggs - 1 pc. per day;
7. Soup: with water, vegetable broth, milk with the addition of cereals or vegetables;
8. Dairy products - cottage cheese, milk, kefir, fermented baked milk and other fermented milk products, mild cheeses. Limit fatty foods;
9. Porridges, cereal dishes - boiled in water until crumbly, steamed or baked puddings;
10. Only the highest grade pasta is allowed in limited quantities. For obesity - exclude;
11. Vegetables, berries, fruits, greens. Everything except tomatoes, sorrel, garlic, onions, beans, radishes, sour berries and fruits;
12. Sweets: marshmallows, marmalade, honey, sugar in limited quantities;
13. Spices: bay leaf, coriander;
14. Drinks: non-acidic fresh juices, rosehip decoction, weak tea. Coffee is acceptable, but very rarely.

Based on the permitted products, it is necessary to develop a menu that meets the following requirements:

• The daily amount of protein consumed is 120 g;
• The daily intake of fat is 80 g;
• The daily intake of carbohydrates is up to 300 g (while sugar should not exceed 60 g);
• Salt - up to 6 g;
• Water, drinks (excluding liquid in dishes) - at least 2 liters.

In addition to diet, it is necessary to give up bad habits, especially drinking alcohol.

In addition to diet and sports (this is the basis of treatment), medications and dietary supplements are also used to maintain liver function.

Treatment of hepatosis with drugs

In addition to the diet, the doctor may recommend therapy using the following drugs:

1. Hepatoprotectors - Essentiale, Essliver, Hepaforte, Essel Forte, Maksar, FanDetox, Liv 52, Ovesol, Gepabene, Galstena, Rezalut Pro. This group of drugs accelerates the metabolic process of the liver - toxins are eliminated faster, while maintaining the permeability of the cell membrane of the organ;
2. Antioxidants - Retinol, Tocopherol;
3. B vitamins;
4. Preparations with selenium.

Antioxidants, selenium and B vitamins can be taken in the form of a vitamin-mineral complex.

Some features of current hepatoprotective agents, drugs based on them and dosage

Hepatoprotectors are developed on the basis of different active ingredients, but they work the same way. Some of them are combined, that is, they not only have the ability to maintain the permeability of the membrane and remove toxins, but also have an antidepressant, choleretic, regenerating, anti-inflammatory effect, and increase appetite.

Active drugs:

1. Phospholipids are substances from which liver cell membranes arise. A deficiency of this substance interferes with the restoration of the organ. Preparations based on phospholipids are effective only when long-term use, can be prescribed for hepatosis that has developed against the background of alcoholism or diabetes mellitus. To the functions of this active substance include: restoration of cell membranes, detoxification, preventing the formation of scar tissue. Phospholipid-based drugs are produced: Essentiale forte N (treatment: 2 capsules/3 times a day, prevention: 1 capsule/3 times a day), Essliver forte (phospholipids + vitamins; initial dosage: 2 capsules/3 times a day). day, after a month take 1 capsule/3 times a day), Rezalut Pro (2 capsules/3 times a day), (1-2 capsules/3 times a day, or in the form of injections). They have virtually no contraindications and are available without a prescription. Side effects include allergic reactions, diarrhea;
2. Ornithine is not used to treat liver pathologies caused by alcohol abuse. Do not take during pregnancy, lactation, or severe renal failure. Preparations: Ornithine (daily dose - 3-6 g, divided into 1-2 doses), ;
3. Ursodeoxycholic acid. It is recommended for use in hepatosis complicated by cholestasis: the drug has a choleretic effect, dissolves stones and prevents the formation of new ones, reduces cholesterol levels in the blood. Do not use in case of liver and kidney failure, large stones, formations with high calcium levels, or bile duct obstruction. Drugs: , Ursodez, Urdoxa, . Dosage 10-15 mg/1 kg body weight, divided into 2-3 doses, taken for at least 6 months;
4. Ademetionine - has a detoxifying effect on the organ and acts as an antidepressant. Can be used for diseases caused by alcohol abuse. Do not use in the 1st and 2nd trimesters of pregnancy and during lactation. Medicines: (1 tablet/3-4 times a day), (2 tablets/3-4 times a day);
5. Milk thistle extract - natural antioxidant, restores liver cells, increases appetite, but treatment of alcoholic hepatosis with this drug will be ineffective. Preparations: Gepabene (1 capsule/3 times a day), Silymar (2 tablets/3 times a day), Sibektan (2 tablets/4 times a day);
6. Fumifera officinalis extract is a herbal preparation recommended for hepatosis, spasm of the gallbladder and ducts. It is forbidden to take during inflammation of the liver, biliary tract, pregnancy and lactation;
7. Thioctic acid is used for hepatosis that occurs due to the development of diabetes mellitus or prolonged use of alcoholic beverages. Do not take during pregnancy, if breastfeeding, lactose intolerance. Preparations: (2 tablets/1 time per day), Lipoic acid, Octolipen (2 tablets/1 time per day), Thiogamma, Thioctacid 600 T, Thioctacid BV, Thiolepta, Espa-Lipon.

Hepatoprotectors are the main medications in the treatment of hepatosis resulting from the development of diabetes or alcoholism.

Drug therapy is only a small part of a long course, which is based on dietary nutrition.

Herbal medicine and traditional medicine for fatty hepatosis. Preventive measures

The components necessary to restore the liver can also be obtained from natural, self-prepared products. In addition to its auxiliary function in treatment, herbal medicine is also well suited for prevention.

Useful tips traditional medicine:

• Infusions of corn silk and rose hips - pour 50 g of dry plant material into 0.5 liters of boiling water and leave for 10-12 hours. Drink 200 g of infusion 2-4 times a day;
• Good to use green tea, fresh carrot juice - they contain a large amount of natural antioxidants;
• Take 1 tsp daily. pine nuts;
• Eat a handful of dried fruits per day. Particularly relevant in winter time of the year;
• Add lemon or peppermint leaves to drinks (infusions, decoctions, tea).

In addition to traditional medicine, the following tips regarding nutrition and lifestyle can be used for prevention:

1. Do exercises daily (at least 30 minutes a day);
2. Monitor your weight;
3. Prepare simple food, do not subject foods to heavy heat treatment;
4. Stop drinking alcohol;
5. Do not take medications without permission - any medications affect the functioning of the liver, and their uncontrolled use can aggravate the condition of the organ. At first glance, the harmless Paracetamol, Suprastin, Aspirin, if the dosage is exceeded or combined with alcohol, are dangerous for the liver.

The result of treatment for a patient who adheres to a diet will be noticeable in about a month - the state of health will improve, the symptoms will disappear, but this does not mean that the course of treatment is over and the organ has recovered.

A long-term diet and periodic examinations using ultrasound and laboratory tests- This is the only way to find out how quickly the liver regenerates.

Fatty liver hepatosis is curable, but it is a long-term struggle in which you can only rely on your willpower.

You should not rely only on medications - this is a small part of the restorative methods used together with the main means of combating the disease - dietary nutrition.

Drugs for fatty hepatosis

Hepatosis is a collective name liver diseases, characterized by disruption of metabolic processes in hepatocytes ( liver cells) and, as a consequence, damage to the cell structure and intercellular substance, metabolic disorders and organ function ( dystrophy). According to the type of metabolic disorder, a distinction is made between fat and pigment ( pigment - a substance that gives color to body tissues) hepatosis.

Steatosis- this is pathological ( deviation from the norm) a condition in which fats accumulate in the cells of the body.

Fatty hepatosis () is the most common reversible chronic process in which in hepatocytes ( liver cells) there is excessive accumulation of lipids ( fat). Gradually, in the liver, an increasing number of cells are replaced by fat cells, which form adipose tissue. As a result of this, the liver increases in size, its color changes to yellowish or dark red, cells die, and fatty cysts (pathological cavities in tissue or organ with contents), organ functions are impaired. Very often fatty infiltration ( accumulation in tissues of substances that are not normally detected) liver goes into fibrosis ( reversible replacement process normal tissue to rough scar locally or throughout the organ), and then to cirrhosis ( irreversible, progressive liver disease in which healthy tissue is replaced by scar tissue).

Fatty hepatosis is a fairly common disease. On average, it affects 10% to 25% of the population in different countries, among them 75% - 90% are people suffering from obesity and diabetes. In Russia, every fourth person suffers from fatty hepatosis.

Anatomy of the liver

The cells that make up the liver are called hepatocytes. The structural and functional unit of the liver is the hepatic lobule. It has the shape of a prism and consists of liver cells ( hepatocytes), vessels and ducts. In the center of the hepatic lobule there is a central vein, and on the periphery there are bile ducts and branches hepatic artery and hepatic vein. Hepatocytes produce up to one liter of bile ( a liquid consisting of bile acids, water, cholesterol, inorganic compounds and involved in the digestion process) per day. Bile acids promote the breakdown and absorption of fats, stimulate small intestinal motility, as well as the production of gastrointestinal hormones. Through intrahepatic small capillaries ( channels) bile enters the larger bile ducts and then into the segmental ducts. The segmental ducts merge into the right ( from the right lobe of the liver) and left ( from the left lobe of the liver) bile ducts, which unite into the common hepatic duct. This duct connects with the gallbladder duct and forms the common bile duct, from which bile flows directly into the lumen of the duodenum.

The liver receives nutrients and oxygen from the blood from its own hepatic artery. But, unlike other organs, the liver also receives deoxygenated blood saturated with carbon dioxide and deprived of oxygen.

There are two venous systems in the liver:

• Portal. The portal venous system is formed by the branches of the portal vein ( gate) veins. The portal vein is a large vessel that receives blood from all unpaired organs abdominal cavity ( stomach, small intestine, spleen), and from the portal vein to the liver. The liver cleanses this blood of toxins, waste products and other substances harmful to the body. Blood cannot enter from the gastrointestinal tract ( gastrointestinal tract ) into the general bloodstream without undergoing “filtration” in the liver.
• Kavalnaya. It is formed from the totality of all the veins that carry blood from the liver. This venous blood is saturated with carbon dioxide and deprived of oxygen due to gas exchange between liver cells and blood cells.

• Protein metabolism. More than half of the proteins ( main building material body), which are produced in the body per day, are synthesized ( are formed) in the liver. The main blood proteins are also synthesized - albumin, blood clotting factors ( acting as a stopper of bleeding). The liver stores amino acid reserves ( main structural components of proteins). In case of insufficient intake or loss of protein, the liver begins to produce ( synthesize) proteins from amino acid reserves.
• Lipid metabolism. The liver plays an important role in fat metabolism. She is responsible for synthesis ( production) cholesterol ( ) and bile acids ( prevent fat droplets from sticking together, activate substances that break down fats into simpler components). One of the functions is also fat storage. Maintains a balance between the metabolism of fats and carbohydrates. With excess sugar ( main source of energy) the liver converts carbohydrates into fats. If there is insufficient glucose intake ( Sahara) the liver synthesizes it from proteins and fats.
• Carbohydrate metabolism. In the liver glucose ( sugar) is converted into glycogen and stored ( stocking up). If there is a lack of glucose, glycogen turns back into glucose and provides the body with the necessary energy.
• Pigment exchange ( pigment - a substance that gives color to tissues and skin). When red blood cells are destroyed ( red blood cells) and hemoglobin ( iron-containing protein - oxygen carrier) free bilirubin enters the blood ( bile pigment). Free ( indirect) bilirubin is toxic to the body. In the liver it is converted into bound ( straight) bilirubin, which has no toxic effect on the body. Direct bilirubin is then excreted from the body, and a small part of it enters the blood again.
• Vitamin exchange. The liver is involved in the synthesis ( production) vitamins and absorption fat-soluble vitamins (A, D, E, K). When there is an excess of these vitamins, the liver stores them in reserve or removes them from the body. If there is a deficiency, the body receives them from liver reserves.
• Barrier function. It is one of the most important functions of the liver. Its purpose is to neutralize and detoxify substances that are formed in the body or come from the environment.
• Digestive function. This function is the constant production of bile by hepatocytes ( liver cells). Bile enters the gallbladder and is stored there until needed. During meals, bile enters the intestinal lumen, thereby facilitating the digestion process. Bile acids promote emulsification ( mixing with water) fats, thereby ensuring their digestion and absorption.
• Enzymatic function. All biochemical reactions accelerated by special substances - enzymes. Such enzymes are found in the liver. And when the body urgently needs any substances ( for example glucose) liver enzymes accelerate the processes of their production.
• Immune function. The liver is involved in the maturation of immune cells ( immunity - totality protective forces body), as well as in many allergic reactions.
• Excretory function. Together with bile, the liver removes metabolic products, which then enter the intestines and are excreted from the body.

• The liver ranks second in weight among all organs ( average weight – 1500 g.).
• 70% consists of water.
• In one hour, about 100 liters of blood passes through the liver and, accordingly, more than 2000 liters per day.
• The liver performs more than 500 functions every day.
• The liver could function for up to 300 years thanks to its unique property– ability to self-heal.
• More than 25% of liver diseases are caused by alcohol consumption.
• About a million occur in liver cells per minute. chemical reactions.
• Currently, more than 50 liver diseases are known.
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• More than 11,000 transplants are performed annually ( transplant surgery) liver.

Forms and stages of hepatosis

Steatosis can be:

• Alcoholic– pathological changes in the liver against the background chronic use alcohol.
• Non-alcoholic(non-alcoholic steatohepatosis - NASH, non-alcoholic fatty disease - NAFD) – fatty degeneration of the liver, which occurs due to poor lifestyle, diet, and various concomitant diseases.

• Stage I – minimal obesity. Fat droplets accumulate in liver cells without damaging hepatocytes.
• Stage II – moderate obesity. Irreversible processes occur in cells, leading to their destruction and death. Their contents enter the intercellular space. Cysts form ( pathological cavities).
• Stage III – severe obesity. Pre-cirrhotic state ( cirrhosis is an irreversible chronic process of replacing liver tissue with scar tissue).

• Focal disseminated – accumulation of small areas of fat in various parts of the liver with an asymptomatic course.
• Severely disseminated – accumulation of fat droplets in large quantities in various parts of the liver with the manifestation of symptoms.
• Zonal – arrangement of lipids ( fat) in various parts of the hepatic lobules ( structural and functional units of the liver).
• Diffuse – liver damage, in which the accumulation of fat occurs evenly throughout the entire lobe of the liver with the appearance of symptoms.

• Primary– congenital intrauterine metabolic disorder.
• Secondary– metabolic disorder that appears as a consequence concomitant diseases, unhealthy diet and lifestyle.

• Small blob obesity– simple obesity, in which pathological processes already occur, but without damage to the liver cells.
• Massive obesity– a more severe course of the disease, in which the structure of hepatocytes ( liver cells) is significantly damaged, which leads to their further death ( necrosis).

• 0 degree of steatosis– accumulations of fat appear locally in hepatocytes.
• I degree of steatosis– accumulations of lipids ( fat) increase in size and merge into foci with damage to liver cells - up to 33% of affected cells in the field of view.
• II degree of steatosis– accumulations of lipids of various sizes, which are distributed over the entire surface of the liver – 33–66% of liver cells ( small-droplet, large-droplet intracellular obesity).
• III degree of steatosis– accumulation of fat occurs not only in the cells, but also outside them with the formation of a cyst ( pathological cavity in tissue), destruction and death of cells - more than 66% of affected liver cells in the field of view.

Causes of liver steatosis

The causes of steatohepatosis are divided into two large groups:

• causes of alcoholic steatohepatosis;
• causes of non-alcoholic steatohepatosis.

Causes of alcoholic steatohepatosis

Causes of non-alcoholic steatohepatosis

Causes of non-alcoholic steatosis

Risk factors are:

• female;
• age over 45 years;
• body mass index ( BMI is the ratio of weight in kilograms to the square of height in meters) more than 28 kg/m2;
• hypertonic disease ( high blood pressure);
• diabetes ( a disease caused by a lack of insulin, a pancreatic hormone responsible for lowering blood sugar levels);
• ethnicity - Asians are most susceptible to the disease, and African Americans have a lower risk;
• burdened hereditary history - the presence of a disease in relatives or factors transmitted genetically.

Symptoms of liver hepatosis

Symptoms of hepatosis

Diagnosis of hepatosis

Diagnosis of the disease includes:

• history taking ( information about the patient’s life, medical history and others);
• inspection;
• laboratory examination methods ( general blood test and biochemical blood test);
• instrumental methods examinations ( ultrasound examination, computed tomography, magnetic resonance imaging, liver biopsy, elastography).

History taking

At the appointment, the doctor will analyze:

• Patient complaints– complaints of pain, discomfort, heaviness in the right hypochondrium, vomiting, nausea.
• History of present illness– the time when the first symptoms appeared, how they manifested themselves, how the disease developed.
• Anamnesis of life– what concomitant diseases the patient has, what lifestyle he leads, what surgical interventions he has undergone, what medications he has taken or is taking and for what period.
• Family history– what diseases did the immediate family suffer from?
• History of the patient's diet– what foods the patient prefers, how often he eats, what diet he follows, are there any allergies to foods, does he drink alcohol ( threshold – 20 g/day for women and 30 g/day for men).

Inspection

During the patient examination:

• The skin and visible mucous membranes are carefully examined, the yellowness of the skin, mucous membranes and its intensity, the presence of scratching and rashes are assessed.
• Percussion is performed ( tapping) and palpation ( probing) abdomen to determine the size and tenderness of the liver.
• Alcohol dependence is also defined - ethicism ( chronic alcohol use). With alcoholism, the patient will have a puffy face, tremors ( trembling) hands, unkempt appearance, smell of alcohol.
• The degree of obesity is determined. To do this, use various calculation formulas normal weight of a person, depending on gender, age, body type, and determine the degree of obesity using tables.

• Body mass index ( BMI). This is an objective factor that evaluates the suitability of a person’s height and weight. The calculation formula is very simple - BMI = m / h 2, that is, it is the ratio of a person’s weight in kilograms and height in m 2. If the index is 25 - 30 kg/m 2 - the patient overweight body ( pre-obesity), if the BMI is more than 30, the patient is obese.
• Calculation of ideal body weight ( BMI). This formula also takes into account the gender of the patient and determines his optimal weight which should be followed. Calculated using the formulas – BMI = 50 + 2.3 x ( 0.394 x height in cm – 60) – for men and BMI = 45.5 + 2.3 x ( 0.394 x height in cm – 60) - for women.
• Measuring your waist circumference with a measuring tape. Used to predict complications and disease risk. If a woman’s waist circumference is more than 80 centimeters, and a man’s is more than 94 centimeters, then the risk of diabetes and hypertension increases ( high blood pressure) and grows with every additional centimeter.
• Ratio of waist circumference to hip circumference. For women, the norm for the ratio of waist circumference to hip circumference is less than 0.85, for men – less than 1.0. Studies have shown that people with an apple body type ( waist wider than hips) are more predisposed to various diseases than people with a “pear-shaped” body type ( hips wider than waist).

General blood analysis

In order to obtain reliable results, the following rules must be observed :

• Blood sampling is carried out in the morning on an empty stomach ( no earlier than 12 hours after eating);
• dinner the night before should be light and early, without coffee and strong tea;
• Alcohol, fatty foods, and some medications are eliminated for 2–3 days;
• physical activity and sauna visits are excluded per day;
• tests are taken before x-ray examination and massage.

• Possible anemia ( anemia). With anemia, the number of red blood cells decreases ( red blood cells) – less than 4.0 x 10 12 /l in men and less than 3.7 x 10 12 /l in women. The amount of hemoglobin also decreases ( oxygen carrier protein) – less than 130 g/l in men and less than 120 g/l in women.
• Signs of possible inflammation. The number of leukocytes in the blood increases ( white blood cells) – more than 9.0 x 10 9 /l, ESR increases ( erythrocyte sedimentation rate) – more than 10 mm/hour in men and more than 15 mm/hour in women.

Blood chemistry

A biochemical blood test may reveal:

• Increased transaminase activity ( ). The level of aspartate aminotransferase increases ( ACT) more than 31 U/L in women and more than 41 U/L in men and alanine aminotransferase ( ALT) more than 34 units/l in women and more than 45 units/l in men. An increase in their concentration in the blood indicates the process of destruction of liver cells.
• Dyslipidemia ( protein metabolism disorder). The concentration of cholesterol increases ( fat-like component of all cells) more than 5.2 mmol/l. HDL concentration decreases ( lipoproteins – complexes of high-density proteins and fats, “good cholesterol”) less than 1.42 mmol/l in women and less than 1.68 mmol/l in men. The concentration of LDL increases ( low-density lipoproteins, “bad cholesterol”) more than 3.9 mmol/l.
• Disturbance of carbohydrate metabolism. Hyperglycemia is observed ( increased blood sugar levels) more than 5.5 mmol/l.
• Hepatocellular failure ( decreased function). Albumin concentration decreases ( major blood protein) less than 35 g/l, blood clotting factors. This indicates the inability of the liver to produce proteins and provide hemostasis ( hemostasis is a complex biosystem that maintains blood in a liquid state under normal conditions, and if the integrity of a blood vessel is compromised, it helps stop bleeding).

Ultrasonography ( Ultrasound)

Indications for liver ultrasound are:

• increased liver size upon palpation;
• liver tenderness on palpation ( palpation);
• changes in biochemical blood test.

• Hyperechogenicity ( increased reflection of waves from tissues) liver- this indicates compaction of organ tissue.
• Enlarged liver ( hepatomegaly) – as a result of inflammatory processes and accumulation of fatty deposits in the liver.
• Fatty infiltration ( accumulation in tissues of substances that are not normally present) more than 30% of the liver– all changes in the liver are detected on ultrasound only when fatty degeneration exceeds 30% of the organ’s area.
• Alternation of hyperechoic areas ( with increased reflection of waves from tissues) and hypoechoic ( with reduced reflection of waves from tissues) – dense areas reflect the rays, less dense areas absorb them, which indicates the heterogeneity of liver damage.

CT scan ( CT)

To conduct the examination, the patient must remove all clothing, jewelry, and removable dentures and put on a special gown. Then he is placed on a bed with a scanning system shaped like a circle. This system is placed in the liver area, after which the scanning probe makes rotational movements, passing X-rays through the patient's body. To improve the quality of imaging, the doctor may do a CT scan with contrast agent, which will more clearly display the structures of the organ on the screen.

Computed tomography is shown:

• with focal ( local) liver damage;
• with unsatisfactory ultrasound results ( ultrasound examination);
• if necessary, a more detailed, layer-by-layer image;
• in the presence of formations, cysts ( pathological cavities in the tissue).

• for mental illness;
• in case of inappropriate behavior of the patient;
• if the patient’s body weight is more than 150 kilograms;
• during pregnancy.

• decreased X-ray density of the liver due to fat accumulation;
• compaction of liver vessels compared to its tissue;
• focal accumulations of fat.

Magnetic resonance imaging ( MRI)

To undergo the procedure, the patient must remove all clothing, jewelry, dentures, and anything that contains metal. He is placed on a bed that slides into the MRI machine. After the procedure, an image of the organ appears on the monitor, which the doctor can study in detail in all positions, sections and from different angles.

Indications for magnetic resonance imaging are:

• the need for more detailed visualization of liver structures;
• presence of cysts, neoplasms;
• greater accuracy in tissue imaging compared to computed tomography, which is more suitable for studying bone structures.

• mental illness;
• patient inadequacy;
• presence of a pacemaker ( a machine in the heart that helps control the heartbeat);
• presence of metal implants ( dental or bone implants);
• claustrophobia ( fear of closed, cramped spaces);
• presence of tattoos containing iron in the ink;
• The patient's weight is more than 160 kilograms.

• liver hardening;
• liver enlargement;
• cysts and neoplasms, determine their size and location;
• heterogeneity of the liver structure;
• focal or diffuse accumulations of fat.

Liver biopsy

After the biopsy, the patient must be monitored by medical staff for four hours. He is strictly forbidden to get up. Apply to the puncture area cold compress. There will be slight discomfort in this area for some time. A day later the ultrasound is repeated ( ultrasonography) liver, general and biochemical blood tests.

Indications for biopsy(excision of a section of an organ for further study under a microscope)liver are:

• Destruction of hepatocytes ( liver cells) for an unknown reason, identified during a biochemical blood test in patients over 45 years of age.
• The need to determine the stage and degree of fatty liver hepatosis.
• Differential diagnosis (exclusion of other diseases) steatosis and other concomitant liver diseases.
• The need for a detailed study of cell structure.
• Suspicion of fibrosis ( reversible replacement of normal organ tissue with scar tissue) or cirrhosis ( irreversible replacement of organ tissue with scar tissue).
• Determining the severity of steatohepatosis, fibrosis, cirrhosis, when other methods are less informative.
• Carrying out surgical operations for obesity or removal of the gallbladder.
• Absolute contraindications to computed tomography and magnetic resonance imaging.

• patient refusal;
• the presence of purulent processes in the liver, intra-abdominal cavity;
• infectious skin lesions in the area of ​​biopsy;
• mental illness;
• increased tendency to bleed;
• focal liver lesions ( tumor);
• tense ascites ( cluster large quantity fluid in the abdominal cavity).

• Degree of steatosis ( 0, 1, 2, 3 ) and type of lesion ( large blob obesity, small blob obesity).
• The presence of structural changes in tissue and their stages ( fibrosis, cirrhosis).
• The presence of other liver diseases that accompany steatosis.
• Inflammatory processes that cannot be detected by most non-invasive methods.

Elastography

Its operating principle is similar to that of ultrasound. The doctor presses on the area of ​​the organ being examined with a special sensor and evaluates the elasticity of the tissue from the image before and after compression. Areas of tissue that have changed in structure contract differently ( due to unequal elasticity) and are displayed on the screen in different colors. Stretch fabric appears in red and green, while stiffer fabric appears in blue. Normally, liver tissue is elastic, but with structural changes ( fibrosis, cirrhosis) its elasticity decreases significantly, the fabric becomes denser and stiffer. The less elastic the tissue, the more pronounced the fibrosis. The procedure is safe and painless, therefore it has no contraindications. It is not performed in pregnant women and patients with ascites, due to the lack of information.

Indications for liver elastography are:

• diagnosis of liver fibrosis;
• establishing the stage of fibrosis.

• structural changes in the liver in the form of fibrosis or cirrhosis;
• severity of fibrosis ( F0, F1, F2, F3, F4 on a special scaleMETAVIR);
• severity of steatosis ( minimal, mild, moderate, severe).

Periodic medical control

Treatment of hepatosis with medications

Treatment goals and main drugs

Diet for hepatosis

Diet therapy should be selected by a nutritionist individually for each patient, taking into account age, weight, gender and concomitant diseases. An incorrectly selected diet can only cause harm. For diseases of the liver and gall bladder, you should follow a specially designed diet - table No. 5 according to Pevzner and diet No. 8 for obesity. The purpose of the diet is to be gentle on the liver.

When following a diet, it is important to remember that:

• Meals should be balanced and contain the required daily protein intake ( 110 – 130 g), fats ( 80 g, 30% – vegetable) and carbohydrates ( 200 – 300 g).
• You should drink enough water ( 1.5 – 2 liters excluding tea, compote, soups).
• It is necessary to limit the amount of salt consumed ( 6 – 8 g) and sugar ( 30 g).
• The number of meals should be up to 6 – 7 times a day ( fractional meals ), dinner 3 – 4 hours before bedtime.
• Food should not be cold or hot.
• Fried foods are completely excluded, and preference is given only to boiled, steamed, baked and stewed foods.
• Avoid foods that irritate the gastric mucosa and increase bile secretion - sour foods, pickles, spices and others.
• You should avoid overeating and eat small portions.
• Alcohol consumption is completely excluded.
• Green tea, coffee, cocoa, chicory, and hibiscus are excluded.

Allowed and prohibited sources of fats for fatty hepatosis

Allowed and prohibited sources of proteins for fatty hepatosis

Allowed and prohibited sources of carbohydrates for fatty hepatosis

• First breakfast– oatmeal with water and milk, low-fat cottage cheese, black tea.
• Lunch– dried fruits, apples, prunes.
• Dinner– vegetable soup with vegetable oils ( corn, olive), buckwheat, compote
• Afternoon snack– bread, unsweetened cookies, rosehip decoction.
• Dinner– mashed potatoes with steamed fish, beet salad, low-fat kefir.

Is hepatosis treated with folk remedies?

Used for the treatment of steatohepatosis :

• Bran. Helps remove excess fat from the body. The bran should be infused in hot boiled water until it cools completely. After the water has cooled, you should take out the bran and eat two tablespoons. They can also be added to porridges and soups. Should be applied up to three times daily.
• Milk thistle seeds. Milk thistle is part of many hepatoprotectors ( gepabene, silymar). Has an antioxidant effect ( protects the liver from the negative effects of oxidative processes, that is, damage to hepatocytes by excessive amounts of reactive oxygen species). Increases immunity, which helps the body cope with many problems on its own. negative factors. To prepare the tincture, milk thistle seeds are poured with boiling water ( 200 ml) for an hour. After this, filter and take 1/3 glass 3 times a day half an hour before meals.
• Immortelle flowers. Immortelle has choleretic effect, normalizes metabolism ( metabolism) liver. Pour 200 ml of immortelle flowers with water at room temperature and heat for half an hour in a water bath. After this, leave for 10 minutes and add warm boiled water to the original volume. Take 1 - 2 tablespoons 3 - 4 times a day 10 minutes before meals.
• Dog-rose fruit. They help remove toxins from the body and enrich it with microelements and vitamins. About 50 g of rose hips are infused in 500 ml of boiling water for 12 hours. Take 150 ml three times a day.
• St. John's wort. Strengthens the walls of blood vessels, has antibacterial effect. Pour 300 ml of boiling water over a tablespoon of dried herb and heat in a water bath for 5 minutes. Strain the resulting mixture and add boiled water to the original volume.
• Mint leaves. Mint leaves have a choleretic effect and are suitable for the prevention of liver diseases. Pour one tablespoon of dried leaves into 200 ml of boiling water. Leave for 20 minutes and take morning and evening before meals.
• Calendula flowers. They have anti-inflammatory, disinfectant, choleretic effects. Helps accelerate metabolic processes in the liver. Pour one tablespoon of calendula into 200 ml of boiling water and leave for 20 minutes. Take 100 ml 3 times a day.
• Chamomile flowers. Has a disinfecting and healing effect. Chamomile flowers should be infused for 20 minutes, then strained and taken 30 minutes before meals 2 - 3 times a day.
• Turmeric. A spice that helps restore damaged liver cells. Can be added to small quantities (1 – 2 pinches) when cooking.
• Pine nuts. Strengthens hepatocytes ( liver cells), preventing their destruction.

Why is liver steatosis dangerous? complications, consequences)?

Fibrosis is a reversible proliferation of dense connective tissue (cicatricial) in the liver when liver cells – hepatocytes – are damaged. In this way, the inflammatory process is limited to prevent its further spread. It has now been proven that fibrosis is treatable. But despite this, fibrosis often progresses to cirrhosis of the liver.

Cirrhosis is a progressive, irreversible disease in which liver tissue is replaced by scar tissue. At the same time, the number of functioning cells is significantly reduced. At the initial stages of the development of cirrhosis, it is possible to stop and even partially restore damaged structures, but with severe course the disease leads to fatal outcome (patient's death). The only treatment is a liver transplant.

Can pregnancy cause fatty liver disease?

Symptoms of fatty hepatosis in pregnant women are:

• widespread skin itching;
• icteric staining of the mucous membranes and skin;
• nausea, heartburn, periodic vomiting, loss of appetite;
• a feeling of heaviness and moderate pain in the upper abdomen on the right;
• stool discoloration;
• general weakness, malaise, fatigue.

Can children get hepatosis?

Hereditary hepatosis - liver damage against the background of genetically determined metabolic disorders, manifested by a violation of intrahepatic bilirubin metabolism ( main component of bile). Manifests itself from birth in the form of chronic or recurrent jaundice ( yellowness of the skin and mucous membranes). These hepatoses are usually benign, with almost no effect on the patient’s quality of life, with the exception of Crigler-Nayjar syndrome, accompanied by a high level of bilirubin in the blood with toxic damage to the central nervous system, heart and internal organs.

Secondary hepatosis develops against the background of concomitant diseases and poor lifestyle. Diabetes mellitus type I ( appears in childhood), obesity, congenital hepatitis, toxic effects of drugs, cholestatic disorders ( bile stagnation), poor nutrition are the main causes of liver disease in children.

Is it possible to cure fatty hepatosis?

Basically, fatty hepatosis is asymptomatic. It is diagnosed accidentally preventive examinations or diagnostic procedures for other diseases. Therefore, it is rarely possible to detect hepatosis in the early stages. Over time, the situation only gets worse and is complicated by fibrosis ( reversible replacement of normal organ tissue with scar tissue) or cirrhosis ( irreversible chronic replacement of tissue with scar tissue). In this case, it is very difficult or impossible to cure the liver.

What is the difference between hepatosis and liver steatosis?

To diagnose steatosis, laboratory and instrumental methods are used. Laboratory methods include general and biochemical blood tests. With steatosis, blood tests reveal an increase in transaminase activity ( enzymes in liver cells that speed up chemical reactions) 4 – 5 times, increasing cholesterol concentration ( fat-like structural element of cells), lipoproteins ( complexes of proteins and fats) low density, increased blood sugar, bilirubin ( bile pigment), decrease in protein concentration and others. Instrumental analyzes include ultrasound examination ( Ultrasound), Magnetic resonance imaging ( MRI), CT scan ( CT), elastography ( Fibroscan) and liver biopsy. These examinations reveal an increase in liver size ( hepatomegaly), local or diffuse fatty accumulations in liver cells, cysts ( pathological cavities in tissues), fibrosis ( a reversible process of replacing healthy liver tissue with scar tissue).

Metabolic disorders affect not only the liver. Therefore, steatosis is characteristic not only of the liver ( as in the case of hepatosis), but also for the pancreas. The causes of pancreatic steatosis are the same factors as for the liver - excessive alcohol intake, obesity, diabetes, taking certain medications and many others. Therefore, when diagnosing “steatosis”, it is necessary to clarify the pathology of which organ we are talking about.

Is it possible to do tubage for fatty hepatosis?

The essence of the method is irritation of the gallbladder with choleretic agents ( drugs or substances that stimulate bile production) means followed by enhanced excretion of bile. This procedure is carried out to prevent bile stagnation ( cholestasis) and the formation of gallstones. It is used for diseases of the liver, gall bladder and bile ducts with symptoms of inflammation and impaired bile secretion. An absolute contraindication to tubage is calculous cholecystitis ( inflammation of the gallbladder due to the presence of stones). This can cause a gallstone to pass from the gallbladder into the bile duct, resulting in a blockage of the duct. In this case, only urgent surgical intervention can help.

Tubage can be performed using a duodenal tube or by taking choleretic drugs with simultaneous warming of the liver. In the first case in duodenum a probe is inserted ( hollow tube) and parenterally ( intravenously) or choleretic substances are administered through the tube. This leads to increased release of bile into the duodenum, from where it is aspirated ( suction with a special device called an aspirator) through a probe. Choleretic substances such as magnesium sulfate solution, sodium chloride solution, 40% glucose solution are taken orally, histamine, atropine and others are taken intravenously.

The second method is probeless tubing ( blind tube). To carry out this procedure, the patient lies on his right side, bending his knees, and drinks a choleretic drug. A warm heating pad is placed under the right side at the level of the liver. Rosehip decoction, magnesium sulfate solution, heated mineral water and others are used as choleretic agents. The patient remains in this position for about 1.5 – 2 hours. The procedure should be carried out once a week for 2 to 3 months.

Which doctor treats hepatic steatosis?

A hepatologist may schedule a consultation with doctors such as:

• Gastroenterologist. This is a doctor who treats the gastrointestinal tract ( Gastrointestinal tract). Chronic diseases of the gastrointestinal tract, as well as surgical interventions on the gastrointestinal tract and long-term parenteral ( intravenous) nutrition lead to improper processing and absorption of nutrients. This leads to metabolic disorders and liver disease with excessive accumulation of fatty inclusions in it.
• Endocrinologist. Doctor specializing in glandular diseases internal secretion (thyroid, pancreas). Endocrine diseases ( diabetes mellitus, thyroid diseases, metabolic syndrome - a combination of metabolic, hormonal and clinical disorders ) lead to obesity and disrupt the functions of many organs. All these factors cause steatosis. Therefore, treatment of this pathology without eliminating or compensating for the original cause has no effect.
• Nutritionist. A nutritionist will help the patient adjust their diet and lifestyle. Since it is poor nutrition that often leads to obesity with all the ensuing consequences ( diseases of the cardiovascular system, endocrinological diseases). He will also determine the deficiency or excess of vitamins, minerals, proteins, fats and carbohydrates coming from food, and select a diet individually for each patient.
• Obstetrician-gynecologist. Pregnancy may be complicated by hepatic steatosis. This disease can negatively affect the fetus and mother, even leading to death. IN severe cases come to artificial termination of pregnancy. Therefore, the hepatologist and obstetrician-gynecologist select supportive drug treatment or perform delivery ( artificial termination of pregnancy) in severe cases of the disease. Taking contraceptives ( contraceptive drugs) changes hormonal background women, which is also a cause of steatosis. In this situation, the gynecologist must choose another method of contraception that does not have a negative effect on the liver.
• Cardiologist. Heart and liver diseases are closely interrelated. Liver dysfunction may be caused by heart failure, chronic oxygen starvation, circulatory disorders. But liver diseases can also lead to aggravation of existing heart pathologies. This is often accompanied by endocrine diseases.
• Expert in narcology. A narcologist treats alcohol addiction, which is the cause of a separate group of steatosis - alcoholic steatohepatosis. If you have liver disease, drinking alcohol is absolutely contraindicated because it can lead to cirrhosis of the liver ( irreversible replacement of normal liver tissue with scar tissue) and subsequently to the death of the patient.

Life expectancy with fatty hepatosis

Cirrhosis is a severe irreversible disease. Life expectancy with liver cirrhosis directly depends on the severity of the disease. With compensated cirrhosis, the body adapts to the pathology with the least negative consequences. Thus, preserved hepatocytes ( liver cells) perform the functions of dead cells. At this stage, life expectancy is more than seven years in 50% of cases. In the subcompensation stage, the remaining hepatocytes are exhausted and are unable to perform all necessary functions. Life expectancy is reduced to five years. With decompensated cirrhosis, the patient's condition is extremely serious. Life expectancy is up to three years in 10% - 40% of cases.

Does hirudotherapy help? treatment with leeches) with hepatosis?

Contraindications to hirudotherapy are:

• pregnancy;
• hypotension ( low blood pressure);
• anemia ( anemia, manifested by low concentrations of red blood cells and hemoglobin);
• hemophilia ( congenital bleeding disorder);
• individual intolerance.

Massage exercises and yoga help improve liver function. All exercises performed while standing on all fours or lying on the right side minimally load the liver and promote the outflow of bile. Among the exercises for the liver are “scissors” ( while lying on your back, scissor-style leg swings are performed), "bike" ( lying on your back simulates cycling), squats, jumps. Breathing exercises also have a beneficial effect on the liver.

To achieve a therapeutic effect from physical activity, you should follow a diet, do not neglect proper rest, and also completely stop smoking and drinking alcohol.

Fatty hepatosis (steatosis) is characterized by fatty liver, the pathology is caused by fatty degeneration in parenchymal epithelial cells. Excessive accumulation of fats provokes cellular rupture, followed by cystic formation in the extracellular tissue space of the organ, resulting in impaired liver function.

In medical practice, there are two forms of steatosis:

• Focal form - triglycerides (fat) are localized exclusively in the intracellular space, in the center of the cell, displacing the cell nucleus.
• Diffuse manifestation is caused by fatty infiltration, leading to cellular rupture and the formation of cystic formations in the organ.

Various reasons determine the type of disease - alcoholic or non-alcoholic character.

Causes

• Genetic predisposition caused by congenital enzyme deficiency of the cytochrome protein;
• Alcoholic liver disease, caused by increased absorption of iron elements in the intestine and the absence of antibodies to hepatitis antigens - virus “C”, which helps to accelerate the progression of the disease;
• Metabolic disorders caused by high levels of fatty acids in the diet.

The microscopic picture of the cells indicates fatty liver lesions of two types - in the form of large-droplet and small-droplet fatty lesions. Atypical manifestations of fatty liver hepatosis without obesity of parenchymal cells are possible, appearing only inflammatory processes, providing the prerequisites for the development of non-alcoholic steatohepatitis - the last step before the development of cirrhosis.

Symptoms

The disease is characterized by slow progression and chronic form currents. In the initial stage, it may not show significant symptoms and is detected, in most cases, during a routine medical examination. Initial symptoms appear:

• signs of acute intoxication and general weakness;
• painful sensations, discomfort in the stomach and compression in the right hypochondrium.

During the examination, a smooth, compacted, round body of the organ is noted, with painful manifestations when pressed. There are signs of an enlarged spleen, palmar erythema is expressed by redness of the palms and soles.

The protective immune functions of the body are reduced, which exposes the patient to colds and infectious diseases. Violations of the barrier function of the liver are manifested:

• stagnant processes of bile (cholestasis);
• yellowness of the skin;
• the presence of bile in the vomit and the manifestation of intoxication;
• signs of abdominalgia in the right hypochondrium.

Chronic alcoholism causes more pronounced symptoms in the form of:

• hyperlipidemia;
• hemolytic anemia;
• manifestations of obstructive jaundice;
• ascitic-edematous syndrome;
• abdominalgia and fever;
• manifestations of painful signs of intoxication.

Diagnosis and treatment of fatty liver

Be careful, photo of the liver (click to view)

Human liver affected by hepatosis Schematic representation of fatty patches

Diagnostics include:

• examination by a specialist - palpation reveals an enlarged liver protruding from under the rib arch;
• ultrasound diagnostics and Dopplerography are used;
• computed tomography and serological studies.

The main direction of treatment is the elimination of the provoking factor, correction of nutrition and lifestyle. According to diagnostic indicators, a narcologist, endocrinologist or cardiologist are included in the treatment process. To facilitate the recovery process, drug treatment is prescribed.

Medicines

In the initial stage of the disease, with a mild course of the disease, a combination therapy is prescribed, consisting of antioxidant protection, stabilization of hepatocyte cell membranes, immunomodulation, providing anti-inflammatory protection and aimed at preventing and relieving dysfunction biliary tract.

Leading place among drugs that help improve functional state organ, occupies - "Ademetionine". The drug is considered complex, as it includes two natural substances - adenosine, which is part of some enzymes, and methionine, which is an amino acid necessary for human health. "Ademetionine" - restores damaged liver cell membranes. Prevents fat oxidation. Stimulates protein synthesis. Possesses effective action not only for alcoholic fatty hepatosis, but also for hepatitis and cirrhosis, due to its mild antidepressant effect.

« », » - bile acid. The drug has a high acid-neutralizing and analgesic effect, regulates the action of the immune system, has the property of regulating cell proliferation (proliferation) and apoptosis (programmed cell death), affects the biochemistry of bile and indicators of steatosis.

"Taurine"- an amino acid that accelerates the removal of toxins from the body in the form of tablets "Dibikor" And , "Taufona" in capsules. They have membrane-stabilizing and antioxidant properties, help increase hepatic blood flow, improve the activity of hepatocytes and the excretion of bile, dissolve bile acids and reduce total cholesterol levels.

Pills "Karsil" contain plant extracts, is a natural drug that has an antitoxic and hepaprotective effect (improving metabolic processes).

Action of essential phospholipids – drug "Essentiale" is aimed at increasing the liver’s resistance to the effects of pathological processes and at its gentle cleansing and restoration.

The doctor may prescribe Heptral or Essentiale in the form of injections.

Included in the complex drug treatment includes excellent membrane stabilizing natural preparation based on field artichoke leaf – « » . Hofitol tablets have a choleretic and protective effect. Provide liver resistance to pathogenic microbes and normalize metabolic processes.

If thickening of bile is noted, a natural remedy is prescribed to improve its outflow. drug – « » . Its action eliminates the feeling of discomfort in the form of heaviness and bloating in the side, and is prescribed to relieve alcohol intoxication, has a strengthening effect.

The use of stanines and fibrates is due to a decrease in blood lipids (cholesterol).

Increased glucose levels (insulin resistance) play an important role in the genesis of fatty hepatosis. The use of insulin sensitizers - Metroformin and Rosiglitazone - improves glucose absorption, activates liver enzymes, helps reduce obesity, and normalizes the effects of hypertension.

They play an important role in the neutralization of various toxic substances. vitamins PP and B2.

The drug treatment plan for fatty liver hepatosis, the dosage of drugs and the duration of the course, should be drawn up by a therapist or gastroenterologist. You should not engage in independent selection of medicines from various sources. Many drugs are fraught with many pitfalls and, if used incorrectly, can cause more harm than good. Entrust your health to specialists.

The use of drug therapy will be untenable if you do not adjust your diet and lifestyle.

Diet

After diagnosis, diet correction is one of the main stages of treatment. It includes:

• Complete exclusion of alcoholic beverages. If this is not immediately possible, alcohol should be diluted with juices or water.
• Limit the consumption of fatty foods - cream, cheeses, margarines, butter and mayonnaise.
• Replacing meat products with seafood and lean fish.
• Cooking by steaming or baking.
• Eating low-fat fermented milk products.
• It is necessary to include various varieties of cabbage in your diet.
• Drink plenty of water – two liters of clean water daily.

Lifestyle

If there was a magic pill, after taking which you can forget about hepatosis, we would talk about it in detail.

Whether people like it or not, drugs alone are usually not enough to remove fatty deposits from the liver. Diet and the absence of bad habits are important. Physical activity is no less important.

The human body is designed in such a way that movement is one of its main functions, developed over millions of years of evolution and completely forgotten only in last years.

There is no need to torture your body with hard and long workouts. In most cases, it is enough to start with light but regular physical activity.

If you are well overweight, start walking. First 30 minutes a day, then 60. If your weight allows, go jogging. Exercising in the morning is also extremely useful. If time allows you to sign up for a gym, then start with a treadmill and stepper, and gradually add weight exercises. And ideally, hire a coach who will help you achieve results in the shortest possible time.

Active image life will improve the general condition of the body, help reduce body weight, and also help in improving the health of your liver.

24.01.2013, 20:54

Dear Colleagues,

Could you please clarify one issue?

The patient, 60 years old, suffers from type 2 diabetes (compensated), hypertension (on prestarium 5 mg at night - blood pressure within 130/80 mm Hg). According to UDS in DA - atherosclerosis with stenoses up to 15-20%.
Hypercholesterolemia (I don’t remember all the numbers, total 7.08 mmol/l, TG and LDL cholesterol are also elevated).
Statins are indicated, but she has had fatty liver disease for several years. There are no complaints, but the CT scan shows quite pronounced changes.
AST is normal, ALT is increased by 2 times, GGT is 178 when the norm is up to 37.

Thank you!

26.01.2013, 13:52

If I'm not mistaken - non-alcoholic fatty disease They even tried to treat the liver with statins; there were small studies with good results (atorvastatin, pravastatin, rozvastatin - but there were very few patients in these studies). I didn’t look for large qualitative studies, maybe they exist. At least NAFLD is not a contraindication to the prescription of statins, nor is an increase in transaminases less than three upper limits of normal.

30.01.2013, 22:27

Dear Colleagues,
What lipid-lowering therapy will be the safest in this case?
Thank you!
Dear colleague!
There are enough publications and recommendations that for NAFLD accompanied by dyslipidemia, statins are indicated and should be used. But choosing a lipid-lowering agent and selecting a dose for this category of people is a difficult task. First of all, you need to decide that a constant increase in ALT is not a marker of a hidden active process in the liver, long-term use medications (eg Cordarone, Nifedipine, etc.) or hypothyroidism (TSH), because It also causes fatty hepatosis. The safety problem when choosing prophylactic use depends not so much on the drug itself (with a certain caveat), but on the dose. It is known that the higher the dose, the more frequent the side effects. A striking example of this is Rosuvastatin, which, with widespread routine use of doubling standard doses, led, on the one hand, to a 2-fold increase in drug concentrations in some very large ethnic groups, and on the other, to a doubling of potential complications. We already know the results: the FDA has practically suspended the use of Rozu- at a dose of 80 mg, and in fact this means 40 mg for Asians. Not in vain European recommendations and GFCI interpret the main thing as safety, and then the dose. We do not treat cholesterol, achieving it at any cost (at the cost both in the literal financial sense and possible complications), but for the sick. Because the ability to influence the development of diabetes mellitus is not related to the lipid-lowering effect, but to the dose of the statin. Preiss D., et al. JAMA 2011. Statins are already on the market famous companies with doses of 15, 30 mg, allowing the possibility of truly titrating in a safe zone, and not doubling “strong” drugs that are especially effective.
Hence, taking into account diabetes associated with NAFLD, it should be recommended to prescribe statins for preventive purposes with a minimum dose (without calculating % according to the standard), gradually titrating it every 4-6 weeks (this is an approximately stable effect of the drug) and if your persistence, compliance and fiscal possibilities will allow reducing LDL to ˂ 1.8 mmol/l or at least 40-50% of the initial level.
Which statin to choose? All statins have good lipid-lowering effects. Any can be used. Chan et al. studied the effect of treatment with Pravastatin 15 mg/day (note the “non-standard” dose of the drug) on ​​the level of insulin in the blood of patients with arterial hypertension. A decrease in blood insulin levels was observed despite concomitant treatment with b-blockers. There is a pleiotropic effect of Pravastatin (40 mg/day) on the antithrombotic effect and inflammatory markers in type 2 diabetic patients Dirkje W. Et al.
In addition, this is a water-soluble statin and is not associated like other statins (which is equally important) with CYP2C9, which can affect the pharmacokinetics of many drugs taken by such patients.

03.02.2013, 14:15

A striking example of this is Rosuvastatin, which, with widespread routine use of doubling standard doses, led, on the one hand, to a 2-fold increase in drug concentrations in some very large ethnic groups, and on the other, to a doubling of potential complications. We already know the results: the FDA has practically suspended the use of Rozu- at a dose of 80 mg, and in fact this means 40 mg for Asians. there is not and has never existed a registered dose of 80 mg of rosuvastatin, the use of the drug in such a dose is not recommended by the manufacturer, those who use the drug in such a dose did and do so contrary to the instructions. The use of rosuvastatin 40 mg in Asian individuals has always been contraindicated by the manufacturer's instructions, and those using similar dosages in this population were acting contrary to the instructions, so the result is not surprising.

Statins from well-known companies have already appeared on the market with doses of 15 and 30 mg, allowing for the possibility of truly titrating in a safe zone, and not doubling “strong” drugs that are especially effective. let's call a spade a spade, such dosages are registered by generic companies, without any evidence base for this, in countries with rather free approaches to registration. Give me at least one original company (namely, original companies research the clinical effectiveness and safety of drugs on the basis of which the registration decision is made, and generic companies, with rare exceptions, limit themselves to bioequivalence studies) that has registered a similar dosage, or an example of a similar FDA-registered dosage. Such dosages are registered for quite understandable reasons.
Because the ability to influence the development of diabetes mellitus is not related to the lipid-lowering effect, but to the dose of the statin. Preiss D., et al. JAMA 2011. . I also recommend that you read the meta-analysis [Only registered and activated users can see links]

CONCLUSIONS: Treatment with statins is associated with a slight increase in the risk of developing diabetes mellitus, low both in absolute numbers and when compared with a decrease in the incidence of coronary events. There is no need to change clinical practice in managing patients with moderate or high cardiovascular risk or have cardiovascular disease

By the way, are you aware that in Russia less than 30% of patients taking statins achieve their target LDL value even according to the old recommendations, not to mention the stricter new ones. Do you know what the average doses of statins used in Russia are? So, we have difficulty even talking about using medium doses, and there is no talk at all about high doses, so your passages are generally irrelevant for Russia

03.02.2013, 18:02

Did you remember to answer your colleague's question?

03.02.2013, 21:30

Did you remember to answer your colleague's question? no, I didn't forget

04.02.2013, 09:43

A dose of 80 mg existed as a maximum dose, and was also used in a randomized comparative study of different doses of statins (STELLAR) as part of the rosuvastatin GALAXY project. And quickly sank into oblivion.
As for generics.

However, further

Simvahexal ® SANDOZ 30 mg


Actavis (Iceland), a generic company, introduced atorvastatin (30 mg tablets) to the Western European market
By the way, if prophylactic use 20 mg of statin is effective, 40 mg is effective, what other evidence base is needed for an intermediate dose of 30 mg? Will not work? Will LDL decrease by only 3 or 4%? So what? Yes, there are no such studies yet, and only because there were no tablets with such doses. The companies produced 10,20,40,80 mg and they worked for them. Doubling the dose led to a decrease in lipids by 6%, and on the other hand, to an arithmetic progression of side complications.
Sesibon for your recommendation with the link. In response, I recommend that you read A Survey of the FDA's AERS
[Only registered and activated users can see links]
Yes, 30% is not enough for Russia. By the way, do you know that in prosperous Western Europe, 70% of patients receive statins, however target values are achieved only in 53% of patients. We haven't gone that far.
What a passage! :bn: I have mercy, on the contrary, for slow, gradual and calculated titration, especially with strong potency of statins. And against the paradigm of formulaic prescribing of standard doses.

04.02.2013, 16:35

I'll start with Orange Book: Drugs Approved by the FDA. Pravastatin sodium PLIVA HRVATSKA DOO 30 mg...

Sorry for the meticulousness, most likely I just don’t know how to use Orange Book properly, but on the corresponding section of the FDA website [Links can only be seen by registered and activated users] by entering “pravastatin” in Search by Active Ingredient, in the resulting list of Approved Drug Products with Therapeutic Equivalence Evaluations with pravastatin did not see either pravastatin produced by PLIVA or a dose of 30 mg, only 10, 20, 40 and 80 mg.
Repeating the same with rosuvastatin, I got only Crestor 5, 10, 20 and 40 mg with this built-in Orange Book search. :ac:

04.02.2013, 16:41

It is tactless of me to vainly incline surnames before each quote, so I will present my answers textually.
A dose of 80 mg existed as a maximum dose, and was also used in a randomized comparative study of different doses of statins (STELLAR) as part of the rosuvastatin GALAXY project. And quickly sank into oblivion. . everything is correct, but it has never been registered and should not be used in clinical practice. Research is conducted to understand what is safe and what is not.

As for generics.
I'll start with Orange Book: Drugs Approved by the FDA. Pravastatin sodium PLIVA HRVATSKA DOO 30 mg.
This is where we should stop, following your request.
However, further
Roxera ® KRKA 5,10,15, 30 mg
Simvabeta ® : betapharm Arzneimittel GmbH 5 mg, 10 mg, 20 mg, 30 mg, 40 mg, 60 mg or 80 mg,
Simvahexal ® SANDOZ 30 mg
Atoris ® KRKA 10, 20, 30, 40 mg
Lipicon (Lipitor, Pfizer) (Atorvastatin) 30 mg Concertina Pharma Pvt. Ltd
Actavis (Iceland), a generic company, introduced atorvastatin (30 mg tablets) to the Western European market; the fact of the matter is that these are generics, including Lipikon