Updated MASLD Guidelines Emphasize New Strategies for Managing Liver Disease Linked to Metabolic Disorders

The recently published executive summary of the EASL–EASD–EASO Clinical Practice Guidelines offers comprehensive updates on the management of metabolic dysfunction-associated steatotic liver disease, formerly known as non-alcoholic fatty liver disease (NAFLD). MASLD encompasses a spectrum of liver conditions ranging from simple steatosis to advanced stages such as metabolic dysfunction-associated steatohepatitis (MASH), fibrosis, cirrhosis, and potentially MASH-related hepatocellular carcinoma (HCC).

Key Definitions and Diagnosis

MASLD is defined as steatotic liver disease occurring in individuals with one or more cardiometabolic risk factors and without significant alcohol consumption. The guidelines stress the importance of early detection, especially in patients with cardiometabolic risk factors, abnormal liver enzymes, or radiological evidence of hepatic steatosis. A stepwise approach is recommended for diagnosing MASLD and assessing liver fibrosis. Initially, blood-based scores like the fibrosis-4 index (FIB-4) should be used. If necessary, imaging techniques such as transient elastography should be followed to evaluate the extent of fibrosis, which is crucial for predicting liver-related outcomes.

Management and Treatment

For adults diagnosed with MASLD, the guidelines emphasize lifestyle modifications as the cornerstone of management. This includes weight loss, dietary adjustments, regular physical exercise, and limiting alcohol intake. Additionally, managing comorbid conditions is crucial. In individuals with type 2 diabetes or obesity, the use of incretin-based therapies like semaglutide and tirzepatide is advised if appropriate.

Bariatric surgery is also recommended for patients with MASLD and obesity, offering a potential intervention to address both conditions simultaneously. In cases where significant liver fibrosis (stage ≥2) is present, and if approved locally, treatment with resmetirom—a medication showing histological effectiveness on steatohepatitis and fibrosis with a good safety profile—should be considered for non-cirrhotic MASH.

Advanced Stages and Surveillance

For individuals with cirrhosis related to MASH, the guidelines recommend a tailored approach that includes adjustments to metabolic drugs, nutritional counseling, and regular surveillance for complications such as portal hypertension and HCC. Liver transplantation is considered for patients with decompensated cirrhosis.

These updated guidelines provide a structured approach to diagnosing and managing MASLD, reflecting the evolving understanding of this complex disease and aiming to improve patient outcomes through targeted interventions and lifestyle modifications.

"Despite significant advancements in the field, several critical aspects of MASLD management still require additional evidence to refine clinical practices," the guideline authors concluded.

Reference:

European Association for the Study of the Liver., European Association for the Study of Diabetes. & European Association for the Study of Obesity. EASL–EASD–EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD): Executive Summary. Diabetologia (2024). https://doi.org/10.1007/s00125-024-06196-3