Clin Gastroenterol Hepatol
MASLD care update: When to treat, what to use, how to monitor
Clinical Takeaway: Use a stepwise, noninvasive pathway (FIB‑4 → elastography/ELF) to identify noncirrhotic MASLD with significant fibrosis, consider resmetirom or semaglutide (not in combination) for eligible patients, and reassess response at 1 year using liver stiffness or ELF reduction thresholds.
What’s new—and what to do now
Clearer risk stratification with noninvasive tests (NITs). The expert panel endorses a standardized, sequential approach to identify patients at highest risk for adverse outcomes. FIB‑4 is the recommended first-line screen, followed—if elevated—by vibration-controlled transient elastography (VCTE) or the Enhanced Liver Fibrosis (ELF) test for second-line stratification. This pathway aims to reduce unnecessary referrals while reliably focusing care on patients with ≥F2 fibrosis.
Who should start drug therapy. For noncirrhotic MASLD/MASH with F2–F3 fibrosis, the consensus supports initiating either resmetirom (THR‑β agonist) or semaglutide (GLP‑1 RA) once cirrhosis has been excluded. Suggested treatment thresholds include liver stiffness 10–20 kPa or ELF 9.2–11.3. Selection should be individualized and guided by shared decision-making and the patient’s cardiometabolic profile (e.g., diabetes, obesity, cardiovascular risk).
No upfront combination therapy. Despite enthusiasm for multimodal approaches, the authors do not recommend starting resmetirom and semaglutide together at initiation, citing insufficient evidence for routine combination use at this time.
How to monitor response. Response should be assessed at 1 year, using objective NIT improvements:
- ≥30% reduction in liver stiffness, or
- ≥0.5-point reduction in ELF
These benchmarks help standardize follow-up and support treatment decisions without repeated biopsy.
Why it matters: With MASLD/MASH prevalence rising globally—and disease-modifying drugs now available—these consensus recommendations provide a practical, test-driven framework to help clinicians identify the right patients, start the right therapy, and measure success consistently in everyday practice.
Source: Younossi ZM, et al. (2026, April 6). Clin Gastroenterol Hepatol. Updated Global Consensus Recommendations for Risk Stratification, Treatment Initiation, and Response Monitoring in Metabolic Dysfunction-Associated Steatotic Liver Disease