Treatment options are indeed limited for patients with NASH. Weight loss has been shown to result in normalization of liver enzymes in some studies [7,8,9] and remains the most viable option for our patients with NASH who is obese. Medical treatment is largely unestablished. Several drugs including the lipid lowering agents, gemfibrozil and clofibrate have been used without much success. Ursodeoxycholic acid has resulted in liver enzyme improvement but no change in the grade of inflammation nor fibrosis [10]. The association of hyperinsulinemic insulin resistance has provided a target for treatment. Metformin, a biguanide that reduces hyperinsulinemia and improves hepatic insulin resistance has been shown to greatly reduce hepatomegaly and steatosis in mice and may potentially be useful in the treatment of NASH in humans [11]. The new PPAR-gamma receptor agonist that improves insulin resistance is another potential useful treatment agent. In fact, a trial utilizing troglitazone has shown encouraging results [12]. Unfortunately, because of reports of rare but serious hepatotoxicity, the drug has now been withdrawn from the market. Rosglitazone has not been used in NASH patients so far. References: 1. Ludwig J, ViggianoT, McGill D, Ott B. Nonalcoholic steatohepatitis. Mayo clinic experiences with a hitherto unnamed disease Mayo Clin Proc 1980;55:434-8. 2. Reid AE. Nonalcoholic steatohepatitis. Gastroenterology 2001;121:710-23. 3. Sanyal AJ, Campbell-Sargent C, Mirshahi F, et al. Nonalcoholic steatohepatitis: association of insulin resistance and mitochondrial abnormalities. Gastroenterology 2001; 120:1183-92. 4. Bacon B, Faravash M, Janney C, Neuschwander-Tetri B. Non-alcoholic steatohepatitis. Hepatology 1999; 30:1103-9. 5. Lee R. Nonalcoholic steatohepatitis: a study of 49 patients. Hum Pathol 1989;20:594-8. 6. Powell E, Cooksley W, Hanson R, Searle J, Halliday J, Powell L. The natural history of nonalcoholic steatohepatitis: a follow-up study of forty-two patients for up to 21 years. Hepatology 1990; 11:74-80. 7. Knobler H, Schattner A, Zhirnicki T, et al. Fatty liver-an additional and treatable feature of the insulin resistance syndrome. Q J Med 1999; 92: 87-96. 8. Vajro P, Fonatanella A, Perna C, Orso G, Tedesco M, DeVincenzo A. Persistent hyperaminotransferasmeia resolving after weight reduction in obese children. J Pediatr 1994; 125:239-41 9. Erikkson S, Eriksson K, Bondesson L. Nonalcoholic steatohepatitis in obesity: a reversible condition. Acta Med Scand 1986; 220: 83-8. 10. Laurin J, Lindor K, Crippin J, et al. Ursodeoxycholic acid or clofibrate in the treatment of non-alcohol-induced steatohepatitis: a pilot study. Hepatology 1996; 23:1464-7. 11. Lin H, Yang S, Chuckaree C, Kuhadja F, Ronnet G, Deihl A. Metformin reverses fatty liver disease in obese leptin-deficient mice. Nat Med 2000; 6: 998-1003 12. Battle E, Hespenheide E, Caldwell S. Pilot study of trosglitazone (Rezulin) for nonalcoholic steatohepatitis (abstr) hepatology 1998; 28:304A. 13. Angulo P, Lindor KD. Insulin resistance and mitochondrial abnormalities in NASH: a cool look into a burning issue (editorial). Gastroenterology2001; 120:1281-5.
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