Noninvasive tests can assess patients with metabolic dysfunction-associated steatohepatitis (MASH) who can be managed in primary care, said Meena B. Bansal, MD, chief of the Division of Liver Diseases at the Icahn School of Medicine at Mount Sinai in New York City, in a presentation at the American College of Physicians Internal Medicine Meeting in San Francisco.

Weight loss, improved diet, physical activity, and medications can significantly reduce liver fat and inflammation. Primary care physicians are well positioned to manage these patients, especially since MASH is closely tied to common conditions like obesity and diabetes. 

Screening for MASH in primary care is important because of its prevalence and because it often is asymptomatic until advanced stages, said Hazem Ayesh, MD, an endocrinologist at Deaconess Health System in Evansville, Indiana, who was not at the presentation but weighed in on the management of MASH in primary care.

Primary care clinicians can also manage metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease. The condition is defined as having at least 5% fat in the liver and is an early flag for more serious liver problems. The condition is potentially reversible but if left untreated may progress to MASH.

Screening 

Clinicians can use tools such as the Fibrosis-4 (FIB-4) calculator to identify patients with MASLD or MASH to help prevent progression to cirrhosis, Ayesh said.

The FIB-4 score estimates the amount of liver scarring using the patient’s age, platelet count, and levels of liver enzymes. A score below 1.3 indicates a low risk for significant fibrosis, necessitating reassessment every 2 to 3 years, barring a change in clinical status, Bansal said during her presentation. 

For scores of 1.3 or higher, Bansal recommends referral to a hepatologist for vibration-controlled transient elastography to assess liver damage. But the noninvasive ultrasound device is increasingly available for use in primary care for early screening, Bansal said. 

The technology, marketed as FibroScan, was approved by the FDA in 2013. The exam takes about 5 minutes, with the patient fasting for 3 hours in advance. Another option is the blood-based enhanced liver fibrosis test, which uses cutoff scores for early, moderate, or advanced fibrosis, Bansal said. 

Scores of 2.67 or higher on the FIB-4 should prompt a referral to hepatology for additional evaluation and liver cancer screening, she said.

If a patient has progressed to MASH, treatment should include medication and lifestyle changes. Clinicians should counsel patients who are overweight or have obesity to follow a Mediterranean-style diet and take up regular exercise. Research shows all-cause mortality decreases with an increase in step counts in these patients, she said. 

Coffee may be recommended because its antioxidant and anti-inflammatory properties have been shown to inhibit liver disease.

Medications Make a Difference 

The recently approved resmetirom and semaglutide are potential game changers for MASH management, Bansal said.

Resmetirom, a thyroid hormone-beta agonist, is an oral, once-daily weight-based tablet that is generally well-tolerated, with nausea and diarrhea as the most common adverse events. In a phase 3 trial to support the drug’s approval, a greater percentage of treated patients showed no worsening of disease and an improvement in fibrosis of at least one stage than placebo patients. But attention to potential drug interactions, including CYP28 inhibitors, is needed, Bansal said. 

Resmetirom “brings hope and expands treatment options; however, access, cost, long-term safety, and real-world effectiveness are still evolving,” Ayesh said. 

Semaglutide can now treat MASH with a 2025 approval for patients with moderate-to-advanced fibrosis, Bansal said. One study showed the drug was effective in treating steatohepatitis with no worsening of liver fibrosis.

“Semaglutide addresses multiple comorbidities while also improving liver outcomes, making it highly practical, and its established safety profile and ease of use make MASH management more feasible in primary care compared to use of newer, liver-specific therapies,” Ayesh said.

However, neither resmetirom nor semaglutide is recommended for patients with cirrhosis or other active liver disease such as primary biliary cholangitis. These should be referred to hepatology specialists. 

Bansal disclosed grant support from the National Institutes of Health, Pfizer, Histoindex, and Siemens, among others. Bansal also serves as a consultant for Petauri, Madrigal, and Fibronostics, among others. Ayesh disclosed no financial conflicts of interest.