Metabolic dysfunctionassociated steatotic liver disease (MASLD) is often asymptomatic, and when symptoms do present, they are nonspecific and rarely trigger alarm bells. The primary care setting is often the first line of defense in diagnosing and staging the disease; as with many other disease states, early treatment and intervention can result in improved outcomes.

“MASH is characterized by the presence of active hepatocyte injury and lobular and portal inflammation in addition to steatosis, and is associated with an increased risk of progression to adverse liver related outcomes and mortality,” wrote Alina M. Allen, MD and colleagues. “In the United States, liver disease secondary to MASH has become the most common indication for liver transplantation among women and the second most common among men.”

Several international guidelines have been developed to help practitioners manage MASLD and the more severe metabolic dysfunctionassociated steatohepatitis (MASH). Although these guidelines have similarities, they also have differences that may impede practical application.

To that end, Dr. Allen and colleagues reviewed several international guidelines and developed clear directives that can be integrated into day-to-day practice. They published their results in Postgraduate Medicine.

Included Guidelines

The researchers examined guidelines developed by the following organizations:

❯ American Association of Clinical Endocrinology (AACE)

❯ American Association for the Study of Liver Diseases (AASLD)

❯ American Diabetes Association (ADA)

❯ American Gastroenterological Association (AGA)

❯ European Association for the Study of Diabetes (EASD)

❯ European Association for the Study of the Liver (EASL)

❯ European Association for the Study of Obesity (EASO)

Some guidelines were created by a single organization, while others were developed collaboratively.

SCREENING l Noninvasive tests, such as the Fibrosis-4 index (FIB-4), have made screening accessible and are highly recommended in patients at risk for MASH. FIB-4 can be easily calculated, incurs minimal cost, and has been shown to have significant diagnostic accuracy for excluding advanced fibrosis. The guidelines each recommend that patients with a low FIB-4 score should proceed with management in the primary care setting, whereas patients with a high FIB-4 score should be considered for a referral to a hepatologist or gastroenterologist.

At-risk patients who should be targeted for screening include those who are overweight, obese, insulin resistant, middle aged, male, Hispanic, type 2 diabetic, and/or have atherogenic dyslipidemia. A preliminary patient assessment should include a complete medical history, alcohol consumption history, and routine lab work.

Currently, screening the general population for MASLD is not recommended, but this may change in the future, given forthcoming novel treatment options.

SURVEILLANCE l The guidelines recommend that clinicians oversee repeated testing with FIB-4 or vibration controlled transient elastography/electrocardiography (VCTE/ELF) for patients with low FIB-4 scores. Although there is still some debate regarding the frequency of retesting, guidelines recommend retesting every 2-3 years for low-risk patients and every 1-2 years for higher-risk patients.

Although liver biopsies remain the gold standard in testing and diagnosis, their invasive nature and increased cost make them impractical for routine surveillance. In the primary care setting, specifically, severe disease presents less frequently. Therefore, FIB-4 testing is sufficient. One study suggests that FIB-4 followed by ELF increases detection accuracy.

LIFESTYLE CHANGES l The guidelines examined recommend positive lifestyle modifications as the first-line therapy for the treatment of MASLD. These changes include nutrition and regular exercise. Patients should also restrict alcohol consumption as part of the treatment protocol. Overall, a multidisciplinary approach to care is essential; this includes managing comorbidities along with continual lifestyle optimization.

“MASH is a major global health concern and its prevalence is expected to increase in the coming years,” Dr. Allen and colleagues concluded. “Evidence based consensus guidelines are available for the screening, diagnosis, and treatment of patients with MASH. However, greater awareness and implementation of these guidelines are required, and ongoing research will help to define new diagnostic and treatment pathways for this patient population.”