Spotlight on MASLD
Recent studies offered recommendations and evidence on screening for metabolic dysfunction-associated steatotic liver disease (MASLD) and steatohepatitis, as well as using medications to reduce the risk of progression.
Three recent studies looked at metabolic dysfunction-associated steatotic liver disease (MASLD) and steatohepatitis (MASH).
A group of researchers surveyed guidelines on MASLD and MASH to develop consensus recommendations, which the authors noted have become more important since the approval of a partial agonist of thyroid hormone beta-receptor, resmetirom, for MASH. The resulting recommendations were published by Gastroenterology on April 11 and call for MASLD risk assessment in any patient with type 2 diabetes, obesity plus a cardiometabolic risk factor, or elevation of liver function tests persisting for at least six months. The next step in screening is to assess alcohol consumption, common comorbidities, and cardiovascular disease risk, the recommendations said.
The document reviews medications that can be used in patients with MASH and diabetes, including pioglitazone, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors, and dipeptidyl peptidase-4 inhibitors, noting that metformin, insulin, and sulfonylureas are not preferred drugs for treatment of diabetes in patients with MASLD or MASH. Vitamin E, ursodeoxycholic acid, and omega-3 fatty acids are not recommended for most patients, the document noted. Resmetirom, on the other hand, should be considered as treatment in patients meeting specific criteria listed by the consensus document.
The document also offers recommendations on preventive screening and vaccinations for patients with MASLD or MASH. A number of algorithms are included in an effort “to provide an easy to use assistance to busy clinicians for providing cutting-edge optimal care to these patients,” the authors said.
A study published by Hepatology on April 2 looked at optimizing use of blood-pressure drugs in patients with MASLD. The target-trial emulation used a database covering 88 health care organizations in the U.S. to identify patients with MASLD in 2011 to 2019. Those who took angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) were propensity score-matched with users of calcium-channel blockers and followed for up to 10 years.
Among the 7,238 pairs, use of an ACE inhibitor or ARB was associated with a significantly decreased risk of mortality (hazard ratio [HR], 0.59; 95% CI, 0.51 to 0.68), major adverse liver outcomes (HR, 0.70; 95% CI, 0.61 to 0.80), including ascites (HR, 0.78; 95% CI, 0.63 to 0.98) and hepatic encephalopathy (HR, 0.67; 95% CI, 0.57 to 0.78), and major adverse cardiovascular events (HR, 0.82; 95% CI, 0.76 to 0.90), but not incident cancer (HR, 0.97; 95% CI, 0.86 to 1.10).
“The mechanisms of how the [renin-angiotensin system] affects liver fibrosis are well established,” said the study authors, who called for their results to be validated in a larger-scale study.
Finally, an industry-funded study published by the American Journal of Gastroenterology on April 14 offered guidance on screening patients with type 2 diabetes for MASLD or MASH. A total of 800 patients referred to diabetes clinics were included (median age, 59 years; 60.6% men). Almost three-quarters of patients (73.6%) had liver steatosis, defined by a controlled attenuation parameter of at least 248 db/m; 16.9% had medium or high risk of advanced liver fibrosis, defined as at least 8.0 kPa. Twelve percent had scores indicating they were high-risk MASH, which could progress to advanced liver disease. A two-tier screening for advanced liver fibrosis by Fibrosis-4 and vibration-controlled transient elastography (VCTE) would have resulted in 8.8% of patients being referred to liver clinics and a false-negative rate of 9.6%. Multivariate analysis showed that overweight or obesity and elevated alanine aminotransferase (ALT) levels were independently associated with liver disease.
The results support recent European recommendations on noninvasive assessment of the risk for advanced fibrosis, the authors said, but also indicate that “referral to VCTE may be recommended for [type 2 diabetes] patients with overweight/obesity and elevated ALT.”