Written by Babatunde Carew
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This American Diabetes Association (ADA) consensus report addresses how to improve screening and early intervention for metabolic-dysfunction-associated steatotic liver disease (MASLD) in patients with prediabetes or type 2 diabetes.
MASLD in type 2 diabetes – a missed opportunity for early action?
MASLD affects over 70% of individuals with type 2 diabetes in the US, with nearly half developing metabolic-associated steatohepatitis (MASH), which significantly increases the risk of cirrhosis, hepatocellular carcinoma (HCC), and mortality. Despite this, liver health remains underprioritized in diabetes care, with limited established screening guidelines. This ADA report serves as a call to action, emphasizing that complications of MASLD are preventable through early diagnosis, appropriate treatment, and long-term monitoring—similar to the management of other microvascular complications of diabetes.
Initial screening
Consider screening all individuals with prediabetes and type 2 diabetes for MASLD. Get a CMP and CBC to calculate the Fibrosis-4 (FIB-4) index, a noninvasive marker of liver fibrosis.
- FIB-4 < 1.3 → high negative predictive value for ruling out advanced fibrosis; consider repeat FIB-4 scoring every 1-2 years.
- FIB-4 > 1.3 → obtain a second tier test to evaluate degree of liver fibrosis (e.g., VCTE or ELF).
- FIB-4 > 2.67 → high of advanced liver disease, consider referral to hepatology even without further evaluation.
Second tier testing
Vibration-controlled transient elastography (VCTE) is the preferred second tier test to obtain a liver stiffness measurement (LSM).
- LSM < 8.0 kPa
- Rules out advanced fibrosis
- Associated with low risk of liver-related outcomes
- Patients can be followed in primary care or endocrinology; consider VCTE every 1–2 years.
- LSM > 8.0 kPa
- Suggests higher risk for advanced fibrosis
- Referral to hepatology is recommended for further diagnostic workup.
- Enhanced Liver Fibrosis (ELF) is a noninvasive, blood-based test used for evaluating liver fibrosis risk, typically when VCTE is unavailable.
- ELF < 7.7 → Very low risk of fibrosis.
- ELF ≥ 9.8 → Indicates advanced fibrosis and increased risk of cirrhosis and liver-related clinical events; consider referral to hepatology.
- ELF > 11.3 → Highest risk group; suggests cirrhosis and is associated with hepatic decompensation — patients should be referred to hepatology.
- Magnetic resonance elastography (MRE) offers greater accuracy than VCTE for staging liver fibrosis but is not ideal for initial risk stratification due to cost and accessibility.
- Liver biopsy should be considered when noninvasive assessments are inconclusive or alternate diagnosis is suspected.
Treatment
Lifestyle modifications are central to treatment of MASLD.
- Nutrition: High-fiber diet, avoid sugary drinks and ultra-processed food.
- Weight loss: Aim for 5% weight reduction to lessen steatosis, 7-10% reduction to reverse steatohepatitis and liver fibrosis.
- Exercise: ≥150 min/week moderate-intensity aerobic activity and resistance activities 2-3 times/week.
- Alcohol: Minimize or ideally abstain from alcohol, especially if F2 fibrosis or greater is present.
- Pharmacotherapy should always be considered for patients with steatotic liver disease, as lifestyle changes alone are often not enough to obtain the desired degree of weight loss.
- GLP-1RAs and dual GIP/GLP-1RAs have been shown to promote MASH resolution and resolve steatohepatitis without worsening of fibrosis.
- Pioglitazone may reverse steatohepatitis and may improve fibrosis.
- SGLT2 inhibitors have demonstrated modest reductions in hepatic steatosis.
- Resmetirom (a selective thyroid hormone receptor β agonist) was recently FDA approved and has been shown to promote MASH resolution and improve fibrosis.
- Metabolic surgery
- Metabolic surgery can improve steatosis, resolve inflammation and hepatocyte ballooning, and lead to fibrosis improvement.
Clinical bottom line
- MASLD affects ~70% of patients with type 2 diabetes, yet routine screening remains uncommon.
- Routine liver assessment should become standard in diabetes care—just like eye, renal, and foot screenings.
- Start with FIB-4 for noninvasive fibrosis risk stratification; second tier testing (VCTE, etc) may be needed to determine who needs a hepatology referral and who can be managed in primary care.
- Cirrhosis and other adverse liver related events due to MASLD are preventable with early identification, lifestyle changes, and appropriate pharmacologic or surgical intervention.
Source
Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) in People With Diabetes: The Need for Screening and Early Intervention. A Consensus Report of the American Diabetes Association. Diabetes Care. 2025 Jul 1;48(7):1057-1082. doi: 10.2337/dci24-0094. PMID: 40434108
