Sociedad Americana de Hirudoterapia

Non-Alcoholic Fatty Liver Disease (Investigational Adjunct)

Investigational adjunct in NAFLD/MASLD; small case series only; weight loss, dietary modification, and resmetirom remain primary.

Tier C — InvestigationalInvestigacionalLast updated: 2026-05-26 · Reviewed by ASH Editorial Board

Resumen para el Paciente

¿Está esto autorizado por FDA para este uso?
Not FDA-cleared for non-alcoholic fatty liver disease (NAFLD/MASLD). FDA cleared medicinal leeches only for venous congestion in microsurgical reconstruction (K040187, June 2004). Use for NAFLD is investigational.
¿Qué evidencia existe?
Tier C (investigational). Only anecdotal reports; there are no randomized controlled trials. Evidence-based management of NAFLD/MASLD per AASLD guidelines: weight loss 7-10 percent (most effective intervention), Mediterranean diet, reduction of fructose and alcohol intake, treatment of metabolic comorbidities (diabetes, dyslipidemia), GLP-1 receptor agonists (semaglutide, tirzepatide) for weight loss and hepatic benefit, resmetirom (newly FDA-approved for MASH with fibrosis stages F2-F3). Vitamin E in selected non-diabetics with MASH. Bariatric surgery in eligible obese patients.
Riesgos principales
  • Bleeding from bite sites, prolonged if early cirrhosis or thrombocytopenia
  • Local skin infection or, rarely, Aeromonas infection
  • Allergic reaction to leech saliva (uncommon)
  • Risk in patients with advanced fibrosis or cirrhosis (variceal bleeding)
  • Risk of missed hepatocellular carcinoma screening
  • Substitution for weight loss, which is the proven primary intervention
  • Delay of resmetirom (FDA-approved for MASH F2-F3), GLP-1, or bariatric surgery evaluation
  • Risk of missed alcohol-related liver disease if alcohol intake is underreported
Quién no debería considerar esto
  • Patients with advanced fibrosis (F3) or cirrhosis (F4) with esophageal varices
  • Patients with thrombocytopenia (platelets <50,000) or INR >1.5 from liver disease
  • Patients with active hepatocellular carcinoma
  • Patients on anticoagulants, with hemophilia, or with severe anemia
  • Pregnant patients
  • Patients who have not engaged with weight loss, diet modification, or evidence-based therapy
Qué preguntar a su clínico
  • Have I had FibroScan, MRE, or biopsy to stage my fibrosis?
  • Am I a candidate for resmetirom (FDA-approved for MASH with fibrosis F2-F3)?
  • Have I been offered GLP-1 receptor agonists (semaglutide, tirzepatide) for weight loss?
  • Am I a candidate for bariatric surgery?
  • Has hepatocellular carcinoma screening been arranged (if cirrhosis)?
  • What evidence specifically supports leech therapy for NAFLD?
  • What is the cost and is it covered by insurance? (typically not covered)
Cuándo buscar atención urgente
  • Vomiting blood or passing black tarry stools (possible variceal bleeding)
  • New abdominal swelling or jaundice (possible decompensated cirrhosis)
  • New confusion or sleepiness (possible hepatic encephalopathy)
  • Severe abdominal pain with fever (possible spontaneous bacterial peritonitis)
  • Spreading redness, warmth, pus, or red streaks (cellulitis)
  • Fever above 38.0 C / 100.4 F or chills
  • Bleeding from a bite site lasting more than 24 hours
  • Hives, facial or tongue swelling, throat tightness, or breathing difficulty

Qué NO significa esto

  • This is NOT FDA-cleared for NAFLD/MASLD.
  • Anecdotal reports do NOT establish efficacy versus weight loss, resmetirom, GLP-1 receptor agonists, or bariatric surgery.
  • It does NOT substitute for weight loss, which is the most effective intervention for fatty liver.
  • It does NOT replace hepatocellular carcinoma screening in patients with cirrhosis.
  • It does NOT mean leech application is safe in patients with advanced fibrosis or coagulopathy.

Referencias cruzadas de seguridad

Clinical Profile

Category
gastrointestinal
ICD-10
K76.0, K75.81
Safety tier
high

Evidence Summary

Non-alcoholic fatty liver disease (now metabolic dysfunction-associated steatotic liver disease, MASLD) is managed per AASLD 2023 guidance with weight loss (>=10% for MASH reversal), Mediterranean diet, exercise, glycemic control, statin therapy when indicated, and resmetirom (FDA-approved 2024) for fibrosis F2-F3. No controlled clinical trial of leech therapy for NAFLD/MASLD has been published; use is investigational and mechanistic only, and the honest evidence grade is D. Any hepatic-decongestion or antiinflammatory rationale for application over a hepatic reflex zone is theoretical, would be confounded by concurrent lifestyle change, and cannot address fibrosis progression.

Treatment specifics

How many leeches, where they are placed, how long a session lasts, and whether to repeat are clinical decisions made by a qualified provider under institutional protocol — not something to self-administer. Discuss the specifics with a clinician experienced in medicinal leech therapy. (Clinicians: switch the audience selector in the top bar to “Clinician” to view protocol detail.)

Key Trials

  1. Andereya S et al. (2008)0

Contraindications

  • Active anticoagulant therapy (warfarin INR >2.0, DOACs, heparin)
  • Hemophilia or other bleeding disorder
  • Severe anemia (Hb <10 g/dL)
  • Active bacteremia or sepsis
  • Known hypersensitivity to leech salivary proteins
  • Pregnancy (relative — first/third trimester)
  • Immunocompromised state with severe neutropenia
  • Cirrhosis (Child-Pugh B/C, or any decompensation)
  • Esophageal varices or portal hypertension
  • Coagulopathy from hepatic dysfunction
  • Concurrent alcoholic or viral hepatitis
  • Hepatocellular carcinoma surveillance abnormality

Related Conditions

Hemorrhoids (Grade II-III, Symptomatic)

Investigational use for symptomatic relief of grade II-III internal/external hemorrhoidal disease; does not address anatomic prolapse.

External Thrombosed Hemorrhoid (Acute, <72h)

Investigational adjunct for acute external thrombosed hemorrhoids presenting within 72 hours; distinct from internal hemorrhoidal disease.

Chronic Anal Fissure (>8 Weeks)

Investigational adjunct for chronic anal fissure refractory to medical therapy; very limited case-report evidence; surgical sphincterotomy remains gold standard.

Hepatic Portal Congestion (Non-Cirrhotic, Investigational)

Highly investigational adjunct for non-cirrhotic hepatic congestion; case reports only; cirrhosis and portal hypertension are absolute exclusions.

Explore the evidence base

Este sitio web proporciona información educativa y no constituye consejo médico, diagnóstico ni recomendaciones de tratamiento. La terapia con sanguijuelas medicinales conlleva riesgos clínicamente significativos y debe ser realizada únicamente por profesionales calificados bajo protocolos aprobados institucionalmente. La autorización 510(k) de la FDA para sanguijuelas medicinales se limita a indicaciones específicas; las discusiones sobre uso investigativo y fuera de indicación se señalan correspondientemente. Para orientación médica específica, consulte a un profesional de salud calificado.

Non-Alcoholic Fatty Liver Disease (Investigational Adjunct) — Hirudotherapy Evidence | ASH