Prof. Sanyal: I think we have made a lot of progress in this field in virtually every area. We have had important studies that have shown the mechanism by which the disease develops. We have had a lot of progress in the last 10 years. We have had numerous studies that have shown the mechanisms by which the disease develops and progresses to cirrhosis. This has allowed us to find drugs to treat the disease and we have now shown that the disease can be reversed and even the fibrosis can be reduced. Specifically the PIVENS trial showed that vitamin E is very effective in improving NASH and the FLINT trial showed that not only can we reduce NASH activity but also improve fibrosis in the liver.
Prof. Sanyal: This has not really been tested in a critical way but our general feeling is that different diets with similar calories have more or less similar effects. There is certainly evidence that the Mediterranean type diet which is high in poly unsaturated fatty acids; fish products, fresh fruits, etc., seem to have a more beneficial effect on the metabolic status and in general have an anti inflammatory effect. Again, this has not been rigorously studied in my view as a treatment of NASH.
Prof. Sanyal: There are a lot of dietary supplements that people push but there is no hard evidence and no scientific evidence that any one supplement is better or worse than the others. It is important to remember that certain supplements even though they are natural products can be toxic. There are plenty of things in nature that are poisonous and so we have to be careful about these and unless we are talking about something that is generally widely shown to be safe, we should not engage in these products, specifically I think things like green tea etc which have been consumed for many centuries and generally have been shown to be safe and are known to have some antioxidant properties and at least theoretically one would think that things like that are probably beneficial. Certainly caffeine has been shown in a number of studies to also be beneficial so coffee is probably not a bad thing either.
Prof. Sanyal: I think there are a lot of drugs, it is very hard to say which is the most promising. There are two drugs that are going to the final stages of drug approval. One is obeticholic acidacid which is a bile acid derivative, which has a fantastic profile of benefitting the liver, but it does cause the cholesterol to go up. It causes patients to itch so it has some issues with it. There is another compound targeting inflammatory targets which also looks quite promising. It all depends on what kind of patients are being targeted, if patients are early in the stage of the disease some of the metabolic compounds such as fatty acid and bile acid conjugates will be very beneficial. Drugs like bovine colostrum may be very beneficial which is also probably a dietary supplement in which looks very promising. But for people with more advanced disease you need more targeted therapies directed at inflammation and fibrosis. Gilead has their galactin trials targeting fibrosis; we are very excited about them and looking forward to the results of those trials to see if they actually will deliver on their promise.
Prof. Sanyal: Yes so bariatric surgery has a very limited role in my view in the treatment of fatty liver disease. This is a disease that affects many people in society and I do not think a surgical is the solution. There are a lot of side effects to bariatric surgery. On the one hand you have to weight the benefits with the risks and the risk benefit ratio does not allow me to say this is a great treatment for everybody with fatty liver disease. However, if someone needs bariatric surgery because they have obesity, diabetes, sleep apnea, or they have multiple comorbidities that are legitimate indications for bariatric surgery and they also have NASH, then I think it is reasonable to proceed to bariatric surgery in that setting but then patients have to be followed properly in the long term. You cannot just operate and tell the patient to go home. They require long term dietary and medical follow up to make sure the patients do well after bariatric surgery.