GLP-1RA plus SGLT2i combination therapy and liver fibrosis progression in MASLD with type 2 diabetes

Background and Aim: The combined use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) may provide synergistic benefits for liver fibrosis in patients with metabolic dysfunction–associated steatotic liver disease (MASLD) and type 2 diabetes mellitus (T2DM). We evaluated the comparative effectiveness of GLP-1RA plus SGLT2i versus GLP-1RA monotherapy on liver fibrosis progression. Methods: We conducted a retrospective cohort study using data from the Mass General Brigham healthcare network (2010–2024). Adults with MASLD and T2DM initiating GLP-1RA therapy were included if their baseline FIB-4 scores indicated low-risk (<1.3) or intermediate-risk (1.3–2.67) categories. Combination therapy was defined as concurrent SGLT2i use for ≥50% of the GLP-1RA treatment period. The primary outcome was fibrosis progression, defined as advancement to a high-risk FIB-4 category. The secondary outcome was hepatic complications (cirrhosis, hepatocellular carcinoma, liver transplantation, or decompensation). Propensity score matching (1:2) was performed to minimize confounding. Results: After matching, 879 combination therapy users were compared with 1690 monotherapy users. Combination therapy was associated with a significantly lower risk of fibrosis progression (3.10 vs. 4.01/100 person-years; HR 0.76, 95% CI 0.61–0.95) and a numerically lower incidence of hepatic complications (1.05 vs. 1.34/100 person-years; HR 0.76, 95% CI 0.53–1.09). Subgroup analyses showed consistent protective associations, with a significant benefit observed among patients with a BMI ≤35. Sensitivity analyses confirmed reduced fibrosis progression in both the ≥90-day and ≥180-day landmark analyses. Conclusions: GLP-1RA plus SGLT2i therapy was associated with reduced fibrosis progression compared with GLP-1RA monotherapy in MASLD and T2DM.