NASH/MASH Resources

Nonalcoholic steatohepatitis or NASH is a form of Nonalcoholic fatty liver disease or NAFLD, in which the liver is inflamed and damaged due to the buildup of fat in the liver.¹ The inflammation and liver damage from NASH can cause fibrosis and scarring and can lead to cirrhosis, where the liver is scarred and permanently damaged.² This can lead to liver cancer. NASH is also associated with cardiovascular disease and type 2 diabetes. People with NASH are more likely to have cardiovascular disease and/or type 2 diabetes and vice versa. Cardiovascular disease is the leading cause of death in people who have NASH. NASH is known as the silent killer, as symptoms can take years to develop. When those symptoms develop, they can include fatigue, weight loss, and the yellowing of the skin or eyes. Currently, about 2%-5% of Americans have NASH. Diagnosis of NASH starts during routine blood tests to check your liver. From there, imaging tests such as ultrasound and MRI will help diagnose the disease and scar tissue that comes with it.⁴

NASH cases in the United States are projected to increase from 2020-2039. During the same time period, the average healthcare cost of NASH will rise from $3,537 per person to $6,601 per person. The cost can vary depending on multiple factors such as age and whether the person has Non-Obese NASH or Obese NASH.⁵

MASH is responsible for high HCRU and increased risk of mortality.^6,7

The complications of MASH are shown below. 

• Cirrhosis: ~$85,000 annually⁸

• Hepatocellular carcinoma: ~$115,000 annually⁷

• Liver transplant: ~$233,000 annually⁷

• Cardiovascular (CV)-related deaths: ~228,750 expected by 2030⁷

• Liver-related deaths: 78,300 are expected to occur annually by 2030⁶

• High FIB-4 is correlated with significantly increased medical costs.⁹

• According to 1 analysis, patients with high FIB-4 scores vs low FIB-4 scores at diagnosis had:

• 78% higher all-cause medical cost ratio

• 12x increase in hospital admissions

• 33x higher liver-related costs

• Healthcare costs increase incrementally with increasing FIB-4 scores. Annualized healthcare costs (in 2020 USD) for patients with the corresponding FIB-4 Score at Index are reported¹⁰:

• ≤0.95: $16,744

• >0.95 to ≤2.67: $19,637

• >2.67 to ≤4.12: $25,728

• >4.12: $34,667

• According to this study, patients with MASH with a high FIB-4 (>4.12) cost over twice as much as a patient with a lower FIB-4 (≤0.95).

Publications

• Nonalcoholic Steatohepatitis: A Review. Sheka A C, Adeyi O, Thompson J, et al. JAMA. 2020, Mar. doi: 10.1001/jama.2020.2298.
• Mechanisms of Fibrosis Development in Nonalcoholic Steatohepatitis. Schwabe R F, Tabas I, Pajvani U B. Gastroenterology. 2020, May. doi: 10.1053/j.gastro.2019.11.311.
• Evidence-Based Clinical Practice Guidelines for Nonalcoholic Fatty Liver Disease/Nonalcoholic Steatohepatitis 2020. Tokushige K, Ikejima K, Ono M, et al. J Gastroenterol. 2021, Nov. doi: 10.1007/s00535-021-01796-x.
• Imaging Biomarkers of NAFLD, NASH, and Fibrosis. Ajmera V, Loomba R. Mol Metab. 2021, Aug. doi: 10.1016/j.molmet.2021.101167.
• Nonalcoholic Steatohepatitis: The Role of Peroxisome Proliferator-Activated Receptors. Francque S, Szabo G, Abdelmalek M F, et al. Nat Rev Gastroenterol Hepatol. 2021, Jan. doi: 10.1038/s41575-020-00366-5.

• Nonalcoholic Fatty Liver Disease 2020: The State of the Disease. Cotter T G, Rinella M. Gastroenterology. 2020, May. doi: 10.1053/j.gastro.2020.01.052.

• Nonalcoholic Steatohepatitis in Children. Xanthakos S A. Clin Liver Dis. 2022, Aug. doi: 10.1016/j.cld.2022.05.001.

• Nonalcoholic Steatohepatitis After Liver Transplantation. Cotter T G, Charlton M. Liver Transpl. 2020, Jan. doi: 10.1002/lt.25657.

• The Burden of Non-Alcoholic Steatohepatitis: A Systematic Review of Health-Related Quality of Life and Patient-Reported Outcomes Younossi Z, Aggarwal P, Shrestha I, et al. JHEP Rep. 2022, Jun. doi: 10.1016/j.jhepr.2022.100525.

• Non-Invasive Diagnosis and Monitoring of Non-Alcoholic Fatty Liver Disease and Non-Alcoholic Steatohepatitis Tincopa M A, Loomba R. Lancet Gastroenterol Hepatol. 2023, Jul. doi: 10.1016/S2468-1253(23)00066-3.

• American Association of Clinical Endocrinology Clinical Practice
  Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver
  Disease in Primary Care and Endocrinology Clinical Settings Cusi K, Isaacs S, Barb D, et al. Endocr Pract. 2022, May. https://doi.org/10.1016/j.eprac.2022.03.010

• Advanced Liver Fibrosis Is Common in Patients With Type 2 Diabetes Followed in the Outpatient Setting: The Need for Systematic Screening Lomonaco R, Levia E G, Bril F, et al. Diabetes Care. 2021, Feb. https://doi.org/10.2337/dc20-1997.

Novo Nordisk provided sponsorship for disease education. AMCP fully controls content of resource. 

_{1. Stanford Health Care. (2018). Nonalcoholic Steatohepatitis (NASH). Retrieved from https://stanfordhealthcare.org/medical-conditions/liver-kidneys-and-urinary-system/nonalcoholic-steatohepatitis-nash.html}

_{2 National Institute of Diabetes and Digestive Kidney Diseases (n.d). Definition and Facts of NAFLD and NASH. Retrieved from https://www.niddk.nih.gov/health-information/liver-disease/nafld-nash/definition-facts}

_{3. American Liver Foundation (2023). Nonalcoholic Steatohepatitis (NASH) complications. Retrieved from https://liverfoundation.org/liver-diseases/fatty-liver-disease/nonalcoholic-steatohepatitis-nash/nash-complications/}

_{4. Johns Hopkins Medicine (2019). Nonalcoholic fatty liver disease. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/nonalcoholic-fatty-liver-disease}

_{5, Journal of Clinical and Experimental Hepatology (2022). The growing economic and clinical burden of Nonalcoholic Steatohepatitis (NASH) in the United States. Retrieved from https://www.jcehepatology.com/article/S0973-6883(22)00532-1/fulltext}

_{6. Hepatology (2023). AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Retrieved from https://journals.lww.com/hep/fulltext/2023/05000/aasld_practice_guidance_on_the_clinical_assessment.31.aspx}

_{7. Journal of Clinical Gastroenterology (2021). Real-world Cormobidity Burden, Health Care Utilization, and Costs of Nonalcoholic Steatohepatitis Patients With Advanced Liver Diseases. Retrieved from https://journals.lww.com/jcge/fulltext/2021/11000/real_world_comorbidity_burden,_health_care.14.aspx}

_{8. Hepatology (2017). Modeling the epidemic of nonalcoholic fatty liver disease demonstrates an exponential increase in burden of disease. Retrieved from https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep.29466}

_{9. International Liver Congress 2022. Total healthcare cost and characteristics associated with higher change in cost in patients with non-alcoholic steatohepatitis (NASH). Retrieved from https://www.postersessiononline.eu/173580348_eu/congresos/ILC2022/aula/-THU_62_ILC2022.pdf}

_{10. Journal of Medical Economics (2023). Healthcare resource utilization and costs of care in the United States for patients with non-alcoholic stetatohepatitis. Retrieved from https://www.tandfonline.com/doi/full/10.1080/13696998.2023.2184967}