A noteworthy shift recently occurred in the field of hepatology, but it didn’t stem from a clinical trial or medical finding. Instead, the change arose from a matter of semantics.
In a special article published online June 24 in the journal Hepatology, telfast zyrtec difference a diverse international consensus group introduced new terminology for one of the world’s most rapidly growing diseases.
The term nonalcoholic fatty liver disease (NAFLD) was to be officially retired, replaced with a more precise and descriptive term ― metabolic dysfunction-associated steatotic liver disease (MASLD).
Additionally, steatotic liver disease (SLD) would be used as an umbrella term encompassing both MASLD and a new subcategory, MetALD, for individuals with MASLD whose alcohol consumption ranges from 140 to 350 g/wk for women and from 210 to 420 g/wk for men. Nonalcoholic steatohepatitis (NASH) would be known as metabolic dysfunction-associated steatohepatitis (MASH).
The new terminology represents small changes with significant implications, especially for patients with MetALD, said the NAFLD nomenclature consensus group’s co-lead, Mary E. Rinella, MD, a professor of medicine at University of Chicago Pritzker School of Medicine and director of the Metabolic and Fatty Liver Program at the University of Chicago Hospitals.
“The only really new thing we did is identify a group of people who meet criteria for MASLD and also drink more than the allowable limit,” she said. “There are tons of these patients who were not being considered before. Now they’re in a category by themselves, where they are going to be able to be studied and better understood.”
Why Make a Change?
The unveiling of the new nomenclature marked the culmination of 3 years of dedicated work that was built upon decades of growing understanding about the pathophysiologic underpinnings of these disease states.
The terms NAFLD and NASH emerged in 1980 to describe patients with chronic liver disease who denied excessive alcohol consumption. However, in the past two decades, it became increasingly evident that the existing terminology was inadequate, the consensus group’s co-lead, Philip Newsome, told Medscape Medical News.
“There was a strong desire for a name that describes what the condition is, rather than what it isn’t; avoiding use of stigmatizing terms, such as fatty and alcoholic; and finally, a nomenclature that could recognize the coexistence of conditions,” said Newsome, former secretary general of the European Association for the Study of the Liver (EASL), and director of the Centre for Liver and Gastrointestinal Research at the University of Birmingham, United Kingdom.
These forces, combined with the recognition that NAFLD and alcohol-related liver disease shared biological processes, created momentum for change.
The idea gained traction with a 2020 article that proposed “MAFLD” as a more suitable term because it would link the disease with its known cardiometabolic risks, Rinella explained.
“We thought that paper was going to be the beginning of a conversation, but what happened instead is it became a full-court press,” Rinella said.
Rinella and Newsome then spearheaded a study to determine whether content experts and patients supported change. The process was led by three prominent international liver societies: EASL, the American Association for the Study of Liver Diseases (AASLD), and the Asociación Latinoamericana para el Estudio del Hígado. The organizations received input from 236 panelists from 56 countries, reflecting the diverse voices essential for addressing a disease with an expanding global prevalence rate.
In this globalized world, you cannot make a decision from on high and then expect everybody to just adopt it, Rinella noted.
The panel utilized a modified Delphi consensus approach, necessitating a supermajority of respondents (67%) to vote in favor of the changes. Seventy-four percent felt that the current nomenclature was sufficiently flawed to consider a name change, and 89% preferred terminology that describes the underlying cause of the disease. A super-majority felt that having “metabolic disease or dysfunction” in the name would help patients better understand their disease (72%) and help healthcare professionals better explain or understand the disease (80%).
The participants settled on the new terminology, and the study resulted in a conclusion: “The new nomenclature and diagnostic criteria are widely supported, nonstigmatizing, and can improve awareness and patient identification.”
It was by no means a simple or straightforward task, according to Rinella. “Anytime you have a contentious issue and you engage a broad range of stakeholders, many of which you know are in disagreement, you’re going to have a difficult time reaching consensus,” she said.
Reassuring Reluctant Adopters
The backing of international liver societies will be crucial to ensuring the smooth and relatively swift adoption of the new nomenclature. The AASLD announced in July that it would begin this process by holding conversations with key stakeholders, including the US Food and Drug Administration, patient organizations, and pharmaceutical industry representatives.
“By engaging external groups, we have gained valuable insights into potential roadblocks or barriers that may impede the full implementation of the new MASLD nomenclature,” AASLD President Norah Terrault, MD, MPH, FAASLD, told Medscape Medical News. “Knowing the types of issues they face will allow us to build an implementation plan that will help guide the field through adoption.”
Even with buy-in from key stakeholders, implementing the changes will be no small feat. It’s a “vast undertaking” that may result in short-term frustrations for some groups, Terrault said.
“For instance, researchers whose work commenced under the old nomenclature may not be able to alter their research papers and will need to publish under the old nomenclature, which may impact which journals their research could be published in,” she said. “Some patient advocacy groups may have the old nomenclature in their names, resulting in a need to rebrand and revise their educational resources. Patient materials need to be updated. Primary care professionals need to be educated. The list goes on.”
These changes demand both patience and time, Terrault said. This applies to those tasked with persuading colleagues and patients, as well as clinicians, many of whom have already expressed some resistance to the updated terminology.
The panel anticipated pushback from clinicians who still advocate for NAFLD. However, Rinella countered that a diagnosis of MASLD requires only one cardiometabolic risk factor and has 99% overlap in most populations. In contrast, the MAFLD diagnostic criteria put forward in 2020 proposed even more restrictive cardiometabolic criteria and greater tolerance for alcohol consumption and would alter the disease natural history, she said.
Concerns have also been raised that replacing NAFLD with MASLD might complicate the value of prior research efforts. However, this should not be a cause for concern, as extensive examination across multiple populations has demonstrated near complete overlap between the two definitions, Rinella said. Biomarker development, natural history studies, and drug development research will remain unaffected, she said.
Some detractors argue that the term “fatty” is sufficiently descriptive and not stigmatizing. However, Newsome contends that the panel’s research unequivocally disproves this notion.
“Our Delphi process demonstrated very clearly that over 50% felt it was stigmatizing, and in particular, there were clear supportive views for this change from many patient groups,” he noted. “The new nomenclature empowers patients to explain what the condition means without the use of emotional language.”
An Opportunity to Improve Care
One compelling way to persuade reluctant adopters of the new nomenclature’s value is to highlight the opportunities it presents.
The updated terminology opens avenues for research and clinical improvements for patients who meet MASLD criteria and consume alcohol at higher levels (MetALD), Newsome said.
“There are questions about the relative contribution of these two factors to liver injury, and I see this as an opportunity to explore this area further,” he said.
Hepatologists should embrace this change as a means of increasing awareness regarding the metabolic origins of the disease, Rinella said. This, in turn, will help identify more patients who require treatment but who are currently overlooked by the existing system, she noted.
“Right now, only around 1% of people with advanced disease are being identified by primary care physicians,” she said. “Hopefully, by elevating the role of metabolic disease, primary care physicians, endocrinologists, and gastroenterologists will be able to identify more patients and bring them to care before they develop cirrhosis.”
Such an outcome would signify much more than a mere semantic shift; it would represent a major advancement in the diagnosis and management of the disease.
Hepatology. Published online June 24, 2023. Full text
John Watson is a freelance writer in Philadelphia, Pennsylvania.
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