MAFLD/MASH/Fibrosis
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Spokane Gastroenterology is prepared to assist providers and patients with diagnosis and management of all stages of MAFLD/MASH/Fibrosis.
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We offer access to FibroScan to determine the stage of fibrosis (F0-F4)
The following is a guide for diagnosis and management of MAFDL/MASH:
STEP 1: Identify Who is at Risk
General population-based screening is not recommended. However, the many professional societies agree that screening should be directed to high-risk groups: •Type 2 diabetes mellitus (T2DM) or prediabetes •Obesity (especially medically complicated obesity) •≥2 metabolic risk factors (hypertension, dyslipidemia, insulin resistance) •Family history of cirrhosis •Incidental hepatic steatosis on imaging An important pearl: aminotransferase levels are frequently normal in patients with advanced MASLD and should not be used alone to exclude significant fibrosis. ALT >30 U/L should be considered abnormal.
STEP 2: Risk-Stratify with Fib-4 Calculation
FIB-4 Index is the recommended first-line noninvasive test for fibrosis risk stratification.
STEP 3: Lifestyle Interventions
The cornerstone for treatment of patients at every stage. Weight loss: ≥5% total body weight reduces hepatic steatosis; ≥7–10% can improve steatohepatitis and fibrosis . In lean patients, even 3–5% weight loss can achieve MASLD remission. Diet : A Mediterranean diet is consistently recommended — rich in vegetables, fruit, whole grains, fish, olive oil, and nuts. Avoid saturated fat, refined carbohydrates, and fructose/sugar-sweetened beverages. Exercise : ≥150 minutes/week of moderate-intensity or ≥75 minutes/week of vigorous- intensity physical activity. Should include both “aerobic” and resistance exercises (weight lifting, resistance bands). Exercise reduces liver fat and improves cardiometabolic parameters independent of weight loss. Alcohol : Even low-level alcohol intake increases risk of adverse liver outcomes in MASLD. Patients with fibrosis ≥F2 should abstain completely. Coffee : ≥3 cups/day may be protective against MASLD and fibrosis.
STEP 4: Manage Cardiometabolic Comorbidities Agressively
Cardiovascular disease is the leading cause of death in MASLD patients. Statins are safe and recommended for CVD risk reduction across the MASLD spectrum, including compensated cirrhosis. Optimize glycemic control, blood pressure, and dyslipidemia per standard guidelines. Metformin, while appropriate for T2DM, should not be used as a treatment for MASH itself, as it does not offer meaningful histological benefit.
Step 5: Pharmacotherapy for MASH with Significant Fibrosis (F2–F3)
Two FDA-approved medications now exist for noncirrhotic MASH with moderate-to-advanced fibrosis: •Resmetirom (Rezdiffra): A thyroid hormone receptor-beta agonist; the first drug approved specifically for MASH (F2–F3). Its mechanism improves liver histology independent of weight loss. •Semaglutide (Wegovy): Approved under accelerated approval for noncirrhotic MASH with F2–F3 fibrosis, in addition to its existing indications for obesity and T2DM. Clinical Trial showed improvement in both steatohepatitis and fibrosis.
Step 6: When to Refer to Hepatology
•FIB-4 >2.67 or >F2 fibrosis on secondary testing. •Consideration of liver-directed pharmacotherapy (resmetirom, semaglutide) for MASH. •Suspected cirrhosis (F4 or suspicious imaging).
Step 7: Bariatric Surgery Option
•Bariatric/metabolic surgery should be considered in patients meeting surgical criteria. •It resolves MASLD/MASH in the most patients without cirrhosis and reduces CVD and cancer mortality.
KEY REFERENCES
American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings: Co-Sponsored by the American Association for the Study of Liver Diseases (AASLD). Cusi K, Isaacs S, Barb D, et al. Endocrine Practice : Official READ MORE
Metabolic Dysfunction-Associated Steatotic Liver Disease. Ali SMJ, Lai M. Annals of Internal Medicine. 2025. READ MORE
Updated Global Consensus Recommendations for Risk Stratification, Treatment Initiation, and Response Monitoring in Metabolic Dysfunction-Associated Steatotic Liver Disease. Younossi ZM, Kalligeros M, Wong VW, et al. Clinical Gastroenterology and Hepatology, 2026. READ MORE
A review of multidisciplinary care in metabolic dysfunction‐associated steatohepatitis and cardiometabolic disease, with a focus on Canada. Kim J, Raggi P, Carreau AM, et al. Diabetes, Obesity & Metabolism. 2025. READ MORE
What Is Metabolic Dysfunction–Associated Steatotic Liver Disease?. Voelker R. JAMA. 2026. READ MORE
A Narrative Review of Lifestyle Management Guidelines for Metabolic Dysfunction-Associated Steatotic Liver Disease. Ivancovsky Wajcman D, Byrne C READ MORE