**3.1 Vitamin E**

800 IU of vitamin E per day is typically advised for patients with biopsy-proven NASH and grade of fibrosis equivalent to or more than 2, who do not have diabetes mellitus. According to certain research, vitamin E helps these patients' steatosis. Nevertheless, there are a variety of data and safety issues when vitamin E doses are administered, so potential risks and benefits of treatment with vitamin E should be explored and the decision to use vitamin E should be made on an individual basis [11]. The American Society for the study of liver diseases advises against the use of vitamin E in individuals with compensated liver cirrhosis and DM although studies that demonstrated the benefits of vitamin E treatment did include these patients. The use of vitamin E is supported by some but not all randomized research; however, inconsistent results may be attributed to variations in these studies' design. A meta-analysis of five of these studies could not find histologic benefits with vitamin E, but there was significant heterogeneity among those studies concerning the synthesis of vitamin E that was used, the patient population, the study duration and lifestyle changes. Nevertheless, the biggest of these studies (pioglitazone vs. vitamin E vs. placebo for the treatment of non-diabetic patients with NASH-PIVENS) showed improvements with the use of vitamin E. The study included the randomization of 247 adults with NASH without DM, who received pioglitazone (30 mg per day), Vitamin E (800 IU per day)

**Figure 4.** *Action of Vitamin E in NAFLD/NASH.*

or placebo for 96 weeks. Patients who were treated with vitamin E, had a higher possibility to have an improvement in the FIB-4 score versus the ones who received placebo (43% vs. 19%) [12]. A meta-analysis of this study showed that the improvement in ALT was more frequent in patients who received vitamin E versus placebo (48% vs. 16%). This is consistent with observational studies that showed improvements in the levels of aminotransferases in patients with NASH that received Vitamin E [13]. This benefit is possibly related to the antioxidative qualities of vitamin E (**Figure 4**). The very high doses of vitamin E (>400 IU per day) have been co-related in conflicting results with the increase in mortality from other comorbidities. So, a very careful approach and individualization is advised. The use of vitamin E should be avoided in male patients with personal or familiar history of prostate cancer [14, 15].
