Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
Do you start a GLP-1 receptor agonist to reduce decompensation risk in an older adult with MASLD and compensated cirrhosis?
If they have an approved indication and can get coverage, I would. Need to follow a bit more closely to ensure not rapid weight loss and protein focused with resistance exercise to avoid worse lean mass loss.
How long do you typically treat patients with phentermine for weight loss and what clinical markers do you follow?
Phentermine has been available since 1959 and remains an affordable and effective medication option added to a full lifestyle-based weight management plan. In people who are generally healthy and without contraindications to the medication, I have had patients used in at least intermittently for sev...
In patients already receiving incretin-based therapy for diabetes/obesity who still have NITs suggesting persistent F2–F3 disease, what clinical signals or NIT patterns lead you to prioritize (1) optimizing anti-obesity incretin dosing, (2) switching incretin class, or (3) adding a thyroid hormone receptor-β agonist for MASH?
If they are already receiving it, ensure doses have been escalated for weight loss (many DM doses don’t get escalated if their sugars stabilize) by their local team. If they are on a full dose, I would add Rezdiffra if insurance will cover it. Or I get them into a study (can access if weight is stab...
How do you approach identifying the dominant, actionable drivers of symptom burden (HE vs infection, renal dysfunction, malignancy-related symptoms, etc.) in decompensated cirrhosis patients with frequent hospitalizations or very limited prognosis, and does that change how aggressively you pursue HE-directed therapy versus other symptom pathways?
It’s important to recognize that decompensated cirrhosis is not a monolith. A patient who has frequent hospitalizations is trying to tell us their phenotype. A simplified approach specific to the symptom is as follows (not thinking about their overall liver disease): 1) Frequent variceal bleeds —> p...
Has recent data showing reduced HCC and cirrhosis risk with antiviral therapy changed your threshold to treat non-cirrhotic chronic HBV patients with ALT 1–2× ULN?
This is an interesting study that certainly warrants consideration and discussion with patients about when to initiate antiviral therapy for chronic hepatitis B. Historically, my threshold for initiating treatment has been guided by ALT elevations, HBV DNA levels, HBeAg status, and evidence of liver...
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...
In the first 4–6 weeks after TIPS, do you deliberately slow ascites decompression (diuretics/paracentesis strategy) in patients with pre-existing hernias, particularly when baseline albumin is higher?
Not necessarily - I tell them to wear an abdominal binding until the hernia resolves.
When patients with MASLD have major metabolic improvement on modern anti-obesity/antidiabetic therapies, how do you interpret changes in NITs over time—do you re-stage prognosis based on updated values, and what magnitude/duration of change is sufficient to de-escalate or escalate liver- specific surveillance?
I would restage (MRE, VCTE) annually, and only after a confirmed decrease into the F2 category on two or three sequential tests would I de-escalate screening (under abundance of caution). VCTE only measures that one focus, and since FL can be patchy, it may underestimate. mRE is average so I look at...
In what circumstances do you offer hepatitis C antiviral treatment to pregnant individuals?
Direct-acting antivirals are still not FDA-approved for use in a pregnant person. None of the major US guidelines currently recommend starting treatment in a pregnant person. However, the AASLD/IDSA guideline suggests a shared decision: "DAA treatment can be considered during pregnancy on an individ...
How do you manage dose titration and nutrition to avoid sarcopenia when prescribing a GLP-1 receptor agonist in a frail older adult with MASLD?
GLP-1 and GLP-1/GIP receptor agonists as a class have been found to be effective in improving MASLD (Loomba et al., PMID 38856224) in patients with and without diabetes. This large class of drugs(more are on the way) also causes significant weight loss, and newer iterations may lower BMI into the no...