New Clinical Practice Guidelines for the Management of MASLD: What are the key approaches?

Hi, I am Sven Franke, I'm professor of hepatology in Antwerp in Belgium. Metabolic dysfunction associated steatotic liver disease or MASLD or MASLD is the most prevalent chronic liver disease worldwide, but unfortunately it's frequently overlooked. The disease emerges in the context of cardiometabolic risk factors, but as the liver is a key metabolic organ, the diseased liver also silently contributes to the severity of metabolic dysfunction as such and also to its deleterious consequences.

Now, given this multidirectional relationship, a multidisciplinary approach is key to management success. European societies for the study of the liver, obesity and diabetes respectively, therefore have recently joined forces and issued a new guideline and I will try to guide you through. First, it is important to highlight that we abandoned the term MASLD and replaced it by MASLD and also the more severe subtype of steatohepatitis is now called MASH instead of NASH.

MASLD-MASH is a positive diagnosis, namely you need to have steatosis in the presence of at least one cardiometabolic risk factor. MASLD can coexist in a given person with other chronic liver diseases, so a second point is that if liver steatosis and or elevated liver enzymes are diagnosed, you should also search for the other causes, hence you should not stop with the diagnosis of MASLD as the only cause. Please also remember that an individual is considered to have elevated liver enzymes.

If the ALT or SGPT is above 33 units per liter in males and 25 in females, thresholds that are thus lower than what most of the labs will report as their upper limit of normal. The three societies state that case finding, mainly aiming at finding people who have a high likelihood of having already some degree of liver fibrosis, that case finding is mandatory. In whom? In individuals with cardiometabolic risk factors, particularly in the presence of type 2 diabetes or obesity with additional metabolic risk factors and in any case if liver enzymes are abnormal.

So how to do that is rather simple. You can start with the FIB4 test which can be easily calculated by the lab. If the FIB4 is below 1.3, you can reassure the patient, but do not forget to reassess after three to five years.

If the FIB4 is above 2.67, the patient should be seen by a hepatologist and if the result is in between, you have two options. You intensify the management of the cardiometabolic milieu and then you re-evaluate or you go straight away to a second line test which could be the assessment of liver stiffness. If the second line test is confirmatory of course, then also a referral is indicated.

The treatment should be truly multidisciplinary, as the treatment of the cardiometabolic risk factors can improve the liver, most notably by weight loss, but also an improved liver condition contributes to improved metabolic health. So again it's a bi-directional relationship. Lifestyle modification is obviously key to improve metabolic health, also to improve liver health.

Some medications used to treat components of the metabolic syndrome, such as the incretin-based obesity medications, also have documented liver benefit and could hence preferentially be used if the patient meets the established indications. Some caution is of course warranted, if people living with cirrhosis, they might require some special attention. Currently there is only one drug, resmitirol, specifically licensed to treat people with MASH with fibrosis.

So, earlier stages obviously require management, including the use of obesity medications, but these are so far not to be considered as specific anti-MASH drugs. In the guideline, we recommend that people with MASH and significant fibrosis should be considered for resmitirol treatment, if it's available. As we do not have the data yet, resmitirol should not be prescribed for people with cirrhosis.

For these patients, unfortunately, there is currently no MESL-D specific treatment available. Metabolic improvement by other interventions, such as bariatric surgery, can also have a benefit for MESL-D, with gastric bypass, and in people with cirrhosis, preferentially sleeve gastrectomy, as the best documented interventions. Bariatric surgery in people with cirrhosis and portal hypertension, as well as in the context of liver transplantation, is not by definition contraindicated, but it is something that should be managed in centers that have specific expertise with these procedures.

There is obviously much more to find in this guideline to assist you in managing people with MESL-D. Go to the App Store or Google Play Store, download the ESL Guidelines app, it's just for free, and you have the guidelines with easy-to-use infographics on your smartphone. I'm Professor Sven Franke for 5-Minute CPD.

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