Shift from NAFLD to MASLD does not necessarily require change in management
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VANCOUVER, British Columbia — Despite recent changes in nomenclature for metabolic dysfunction-associated steatotic liver disease, an expert here noted that clinical pathways largely remain the same and require reinforcing.
“Fatty liver has changed its name and this is a result of a global process — a multiyear, multisociety process — that included over 50 countries that decided that we really shouldn’t call the name of a disease non-something,” Cynthia Moylan, MD, MHS, of Duke Health, said in a presentation during the ACG Annual Scientific Meeting. “We should call it what the underlying etiology is.”
“The prevalence and global burden of MASLD is really huge,” Moylan continued. “The global prevalence of MASLD is now 30% and it has increased by 50%. ... It really doesn’t spare anywhere in the world.”
Clinical care pathways
Moylan emphasized that as a result of this global burden, hepatologists cannot fully care for all of the people with or at risk for MASLD and metabolic dysfunction-associated steatohepatitis (MASH).
“We’re really going to need help as hepatologists to make sure we’re caring for the right people,” she said.
Moylan discussed the clinical care pathways that primary care providers, endocrinologists and gastroenterologists should utilize to refer patients for further testing or care by a hepatologist.
“The primary process is really risk-stratifying for advanced fibrosis,” she said. “And what does that mean? That means really ruling out advanced fibrosis, so those people who are considered low risk can stay in primary care and we can be that one hepatologist caring for all those people with MASH cirrhosis.”
The first step is identifying those at risk because of two or more metabolic risk factors, type 2 diabetes or steatosis on any imaging modality. Once identified, take a history and run lab tests, followed by a noninvasive test for fibrosis. Though there are many noninvasive tests, Moylan recommends FIB-4 because it is easily calculable and has a high negative predictive value.
“Refer for biopsy if there are discordant results or diagnostic uncertainty” after a noninvasive test, she added.
If the patient falls into the category of low risk, they should stay under the care of their primary care physician but continue to be monitored.
“You should really reassess these patients with two or more metabolic risks, if they have diabetes or prediabetes, once a year,” Moylan said.
If they fall within the category of high risk, they should get a referral to a hepatologist.
MASLD, MASH management
Moylan explained how MASLD and MASH can be managed by physicians at different levels of risk. Though all should include lifestyle changes and weight loss, the path may also include medication, surgical management or a clinical trial.
“The most important thing to remember is that this is an individualized discussion and management plan with each patient — not everyone with MASLD and MASH and fibrosis is the same,” she said. “They all should get lifestyle modifications, but really maybe the steatosis is driven by obesity in one patient, by hyperlipidemia in another patient and by insulin resistance and diabetes in another patient. What you’re going to use in terms of FDA-approved medications is really going to target those comorbidities.”
She also noted that physicians should know when to refer for bariatric surgery or for clinical trials of new medical management options.
“It’s important to remember that most of these patients will be cared for outside of GI hepatology,” Moylan concluded. “It really behooves you to educate your colleagues in primary care and endocrinology about the proper stratification of these patients.”
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Moylan CA. The latest in the management of patients With MASLD. Presented at: ACG Annual Scientific Meeting; Oct. 20-25, 2023; Vancouver, British Columbia (hybrid meeting).
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