A Pragmatic Management Approach for Metabolic Dysfunction-Associated Steatosis and Steatohepatitis

Obesity and associated insulin resistance induce a chronic metaboinflammatory state that lead to injury and dysfunction of multiple organs resulting in a cluster of noncommunicable diseases such as type 2 diabetes mellitus, hypertension, cardiovascular disease, chronic kidney disease, and metabolic dysfunction-associated steatotic liver disease (MASLD). Metabolic dysfunction-associated steatohepatitis (MASH) is a histologically active form of MASLD and characterized by greater injury and inflammation and progresses to cirrhosis with greater certainty than steatosis alone. The progression to cirrhosis is characterized by increasing fibrosis. The goal of treatment of MASLD/MASH was to improve the metaboinflammatory state i.e., the root cause of the liver disease and to prevent fibrosis progression to cirrhosis whereas in those who already have cirrhosis need additional care to prevent portal hypertension-related outcomes. Fibrosis regression is thus a key objective of treatment. The recent approval of resmetirom for MASH with fibrosis and the use of glucagon-like peptide-1 receptor agonists for obesity and type 2 diabetes has increased awareness of these NCDs and resulted in the growing demand for liver assessment and care in obese individuals. Patients with MASLD also have multiple metabolic comorbidities which represent competing threats to life, and the care of the patient requires both assessment of the totality of the risk and a more holistic approach integrating the care of all of the threats to life. Here, we provide a pragmatic and easily implementable risk-based approach to the evaluation and management of MASLD.