Overview
This podcast episode features an expert discussion on metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as fatty liver disease. The hosts and guest hepatologist Dr. Elliot Tapper review diagnostic strategies, new terminology, laboratory and imaging tools, management approaches, and recent therapeutic developments.
New Terminology & Approach
- MASLD replaces "nonalcoholic fatty liver disease" (NAFLD) to emphasize a positive, person-first diagnosis linked to metabolic dysfunction.
- Language used with patients is tailored to their health understanding and preferences.
- Key causes of steatotic liver disease include metabolic dysfunction, alcohol, and medications; rarely, hepatitis or genetic disorders.
Diagnosis & Evaluation
- ALT >30 for men or >20 for women considered abnormal; lab reference ranges may not be reliable.
- Primary history targets alcohol use, metabolic syndrome, and medication review (use tools like LiverTox for med review).
- Objective alcohol use measurement with phosphatidylethanol (PEth) testing; discuss rationale for transparency.
- Routine screening for hepatitis B and C recommended; test and treat when identified.
- Physical exam focuses on signs of cirrhosis (e.g., spider angiomata), but most MASLD patients have normal exams.
Risk Stratification & Prognosis
- Prognosis based on liver fibrosis, not just presence of steatosis or inflammation.
- Initial step: Calculate FIB-4 score (age, platelet count, AST/ALT) to assess fibrosis risk.
- FIB-4 <1.3 (age <65) or <2.0 (age ≥65) indicates low risk.
- FIB-4 >2.67 indicates high risk.
- If FIB-4 is elevated, proceed to non-invasive liver stiffness measurement (transient elastography/FibroScan).
- Rule of fives: Stiffness <5 kPa is normal, >10 suspect advanced fibrosis, >15 high suspicion of cirrhosis, >20 almost definite, >25 high risk of complications.
Laboratory & Imaging Workup
- Restrict testing to targeted hepatic markers unless atypical findings.
- Avoid over-testing (e.g., ferritin, autoimmune markers) unless initial workup or follow-up suggests.
- Imaging (ultrasound or elastography) reserved for unclear diagnosis, abnormal FIB-4, or clinical suspicion.
Treatment & Management
- First-line management is lifestyle modification: carb reduction, reduction of sugar-sweetened beverages, and increased activity.
- Emphasize small, sustainable dietary changes and motivational interviewing.
- Targeted weight loss: 5% reduces steatosis, 7% reduces inflammation, 10% may reverse fibrosis.
- Consider referral to hepatology/fatty liver clinics for advanced fibrosis or complicated cases.
Pharmacologic Therapies
- GLP-1 agonists (e.g., semaglutide) and other weight loss drugs may help in early-stage disease.
- Resmetirom recently approved for fibrosis reduction in biopsy-proven cases without cirrhosis.
- Metformin and statins are not hepatotoxic and should not be discontinued if indicated.
- Vitamin E for biopsy-proven NASH can reduce inflammation but requires risk counseling.
- SGLT2 inhibitors show promise in epidemiologic studies but lack RCT evidence for direct benefit.
Decisions
- Use FIB-4 and targeted labs for initial assessment of abnormal liver enzymes.
- Reserve advanced imaging and serologic fibrosis panels for non-low-risk patients.
- Consider new pharmacologic agents for patients with significant fibrosis after lifestyle optimization.
Action Items
- TBD – All Providers: Assess patients with abnormal liver enzymes using FIB-4, PEth test if alcohol use is in question, and screen for hepatitis B and C.
- TBD – Primary Care: Initiate lifestyle counseling and consider early referral for advanced fibrosis or inadequate response.
Recommendations / Advice
- Prioritize diagnosing and ruling out alcohol as a contributing factor.
- Use sequential testing to confirm fibrosis risk before specialist referral.
- Focus lifestyle advice on achievable dietary changes, especially sugar reduction.
- Avoid unnecessary broad diagnostic panels unless indicated by clinical context.
Questions / Follow-Ups
- Clarify specific insurance and access considerations for resmetirom and similar new therapies.
- Long-term management strategies post-fibrosis improvement remain to be defined.