GIandHepatology.com

Liver Disease

What Is the Current Approach to MASLD and MASH?

Answer in brief: Metabolic dysfunction-associated steatotic liver disease (MASLD) is managed according to fibrosis risk rather than steatosis alone. The practical sequence is to confirm a compatible metabolic phenotype, exclude important competing liver diseases and clinically significant alcohol exposure, use FIB-4 as an initial fibrosis risk assessment, escalate intermediate/high-risk patients to elastography or another validated noninvasive test, and intensively treat obesity, diabetes, dyslipidemia and cardiovascular risk. Patients with MASH and stage F2-F3 fibrosis now have disease-specific pharmacologic options in the United States, including resmetirom and, following 2025 regulatory/guideline developments, semaglutide for appropriate patients.

The name changed, but the clinical priority did not

The newer MASLD/MASH nomenclature emphasizes metabolic dysfunction and reduces stigmatizing terminology. Clinically, the most important prognostic variable remains fibrosis stage. Simple steatosis without advanced fibrosis usually carries lower liver-related risk than MASH with significant fibrosis.

Find the patients who have fibrosis

A large MASLD population cannot be triaged by liver biopsy. FIB-4 is a practical first test because it is inexpensive and has useful negative predictive value. Patients above the low-risk threshold should undergo a secondary fibrosis assessment, commonly vibration-controlled transient elastography. MRE can be useful when uncertainty remains or greater accuracy is required.

Treat the metabolic disease aggressively

Weight reduction, physical activity, diabetes control, blood-pressure management and lipid management are foundational. Cardiovascular disease remains a major cause of morbidity and mortality in MASLD, so hepatology management should not become liver-only management. Statins should not be withheld solely because MASLD is present when otherwise indicated.

Liver-directed therapy has entered routine practice

Resmetirom was incorporated into AASLD guidance in 2024 for selected patients with noncirrhotic MASH and moderate-to-advanced fibrosis. In 2025, phase 3 ESSENCE data showed that semaglutide 2.4 mg weekly improved key histologic outcomes in biopsy-defined MASH with F2-F3 fibrosis, and AASLD subsequently issued guidance on patient selection and monitoring. Choice between liver-directed agents should incorporate obesity, diabetes, lipid profile, contraindications, side-effect profile and fibrosis stage.

Cirrhosis is a different management state

Once cirrhosis is present, management expands to surveillance for hepatocellular carcinoma, portal-hypertension assessment, vaccination, nutrition, avoidance of decompensation and transplant consideration when appropriate. Drug indications for noncirrhotic F2-F3 MASH should not simply be extrapolated to decompensated cirrhosis.

A practical clinical approach

  1. Confirm MASLD phenotype and assess alcohol and competing liver diseases.
  2. Calculate FIB-4 as initial fibrosis risk assessment.
  3. Use VCTE/ELF or another secondary test when FIB-4 is not clearly low risk.
  4. Refer or further stage patients with high-risk results or discordant findings.
  5. Treat obesity, diabetes, lipids, blood pressure and lifestyle risk factors.
  6. Consider disease-specific pharmacotherapy only in patients who meet evidence-based fibrosis/clinical criteria.
  7. If cirrhosis is present, initiate cirrhosis-specific surveillance and complication prevention.

Common errors to avoid

  • Focusing on liver fat while ignoring fibrosis stage.
  • Referring every patient for liver biopsy.
  • Failing to address cardiovascular risk.
  • Using FIB-4 as a diagnostic test for MASH rather than a fibrosis triage tool.
  • Applying F2-F3 drug indications to decompensated cirrhosis without evidence.

What should trainees remember?

MASLD management is principally a fibrosis-risk pathway plus aggressive metabolic care. The major recent change is that selected patients with F2-F3 MASH now have evidence-based liver-directed drug options.

Free further reading from Dr. Alan B. R. Thomson

See Dr. Thomson's Guideline-Based Management in Hepatology and Best Practice Guidelines in Hepatopancreaticobiliary Disorders. Their framework should be supplemented with the 2024-2025 AASLD drug-specific updates.

Frequently asked questions

What determines liver-related risk in MASLD?

Fibrosis stage is the strongest practical predictor of liver-related outcomes.

Does every patient need elastography?

No. FIB-4 can identify many low-risk patients; secondary testing is most useful when FIB-4 is elevated or clinical concern remains.

Are there now approved drugs for MASH?

Yes. In the United States, resmetirom and semaglutide are available for selected patients with noncirrhotic MASH and stage F2-F3 fibrosis.

References

1. Thomson ABR. Guideline-Based Management in Hepatology. CAPstone Academic Publishers; 2015. ISBN 978-1502928078.

2. Thomson ABR. Best Practice Guidelines in Hepatopancreaticobiliary Disorders. CAPstone Academic Publishers; 2024. ISBN 979-8861272735.

3. Rinella ME, et al. AASLD Practice Guidance on the Clinical Assessment and Management of Nonalcoholic Fatty Liver Disease. Hepatology. 2023;77:1797-1835.

4. AASLD. Resmetirom Therapy for MASLD: October 2024 Update to Practice Guidance.

5. AASLD. Semaglutide Therapy for MASH: November 2025 Update to Practice Guidance.

6. Sanyal AJ, et al. Phase 3 Trial of Semaglutide in Metabolic Dysfunction-Associated Steatohepatitis. N Engl J Med. 2025;392:2089-2099.

Suggested free reading

Continue with these free books by Dr. Alan B. R. Thomson: