NAFLD/MASLD and NASH/MASH are rising globally alongside obesity and metabolic comorbidities, with NAFLD affecting roughly a quarter to a third of adults and often going undiagnosed. As fibrosis prevalence increases, projections suggest disproportionate growth in advanced disease (F3–F4) by 2030—driving higher rates of decompensation, hepatocellular carcinoma (HCC), and NASH-cirrhosis–related mortality. Fibrosis stage (and steatohepatitis) is the key predictor of progression: “at-risk” NASH (≥F2) carries a substantially higher liver-related risk, and once cirrhosis is present, surveillance for HCC/varices and monitoring for decompensation becomes central. Across NAFLD overall, cardiovascular disease and non-hepatic malignancy are leading causes of death, while liver-related death predominates as fibrosis advances.

The guidance emphasizes targeted screening and stepwise risk stratification rather than population-wide screening. In primary care/endocrinology, FIB-4 is recommended as the first-line, low-cost rule-out tool, with more frequent reassessment (every 1–2 years) for patients with prediabetes/T2DM or multiple metabolic risk factors. Secondary assessment typically uses VCTE (or ELF/MRE when appropriate) and referral to hepatology for intermediate/high risk, discordant results, or persistent aminotransferase elevation. It also underscores NAFLD’s tight links to obesity (especially visceral/“android” adiposity), T2DM (highest-impact risk factor for fibrosis progression and HCC), hypertension, dyslipidemia, obstructive sleep apnea, and CKD—so management must aggressively address cardiometabolic risk. Lifestyle therapy remains the foundation (dietary quality, exercise, weight loss when indicated), with multidisciplinary care to improve long-term adherence and outcomes.

Reference: Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023 May 1;77(5):1797-1835. doi: 10.1097/HEP.0000000000000323. Epub 2023 Mar 17. PMID: 36727674; PMCID: PMC10735173.

A recent American Diabetes Association (ADA) consensus report lays out a practical clinical care pathway for people with prediabetes or diabetes and metabolic dysfunction–associated steatotic liver disease (MASLD). It emphasizes that earlier identification is achievable using noninvasive tests (NITs) to stratify fibrosis risk and help prevent progression to cirrhosis. It also highlights a rapidly evolving treatment landscape, noting FDA approval of resmetirom in 2024 as the first pharmacotherapy for metabolic dysfunction–associated steatohepatitis (MASH). The report underscores emerging evidence for metabolic agents—such as semaglutide—showing improvements in steatohepatitis and fibrosis in phase 3 data. The guidance frames MASLD-related cirrhosis as largely preventable when clinicians pair timely diagnosis with lifestyle intervention and evidence-based pharmacologic options for obesity and type 2 diabetes.

The report additionally focuses on “how to deliver care” after diagnosis: long-term monitoring, integration of risk-stratification pathways into EMRs, counseling on alcohol intake, and special considerations for diabetes management in cirrhosis and HCC risk. Because MASLD in diabetes is complex and involves both hepatic and extrahepatic disease, it strongly recommends interprofessional, team-based care (primary care and endocrinology supported by RDNs, DCES, behavioral health, obesity specialists, pharmacists, and hepatology/GI). Overall, it aims to catalyze a shift toward routine screening and proactive management—treating fibrosis risk like other diabetes complications—so patients receive individualized education, coordinated care, and surveillance that improves outcomes and quality of life.

Reference: Cusi K, Abdelmalek MF, Apovian CM, et al. Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) in People With Diabetes: The Need for Screening and Early Intervention. A Consensus Report of the American Diabetes Association. Diabetes Care. 2025 Jul 1;48(7):1057-1082. doi: 10.2337/dci24-0094. PMID: 40434108.

This AASLD-led update gives practical, clinician-facing guidance for using resmetirom—especially where the FDA label is less prescriptive—covering who to treat, concomitant therapy, and monitoring. It recommends treating adults with MASH and F2–F3 fibrosis, typically identified without routine biopsy using noninvasive liver disease assessments (NILDA)—preferably imaging-based VCTE/MRE. Treatment candidates also should have evidence of steatosis plus cardiometabolic risk factors and no competing causes (including higher alcohol intake). Blood-based tools can be used when imaging isn’t available, and a reasonably recent historical biopsy can still support decisions.

Management keeps lifestyle and metabolic risk control as the foundation and flags common real-world issues: drug interactions (CYP2C8—dose reduction with moderate inhibitors like clopidogrel) and statin dose caps when co-administered. Monitoring focuses on tolerability and safety (most AEs are diarrhea/nausea; rare hepatotoxicity warrants periodic hepatic panels) and on whether treatment is helping. At ~12 months, it suggests repeating the same NILDA and tracking ALT/fibrosis surrogates, using pragmatic thresholds (about 20% MRE or 25% VCTE change) to gauge improvement vs worsening. If signals are mixed, continuing therapy should be individualized, recognizing that stabilizing fibrosis may still be valuable.

Reference: Chen VL, Morgan TR, Rotman Y, et al. Resmetirom therapy for metabolic dysfunction-associated steatotic liver disease: October 2024 updates to AASLD Practice Guidance. Hepatology. 2025 Jan 1;81(1):312-320. doi: 10.1097/HEP.0000000000001112. Epub 2024 Oct 18. Erratum in: Hepatology. 2025 Apr 1;81(4):E133. doi: 10.1097/HEP.0000000000001186. PMID: 39422487.