When Severity Shapes Care MASH management reflects metabolic risk & disease stage in practice.
Combination Therapy to Target Areas of Concern
CASE 1
A 48-year-old man with type 2 diabetes, visceral obesity, and hypertension presented with mild liver enzyme elevation and hepatic steatosis on ultrasound and was initially reassured. After relocating, a new PCP screened for complications and calculated a FIB-4 of 3.15, referring him for transient elastography. The findings were liver stiffness of 14kPa (MASH). Already on antihypertensives and GLP-1, he started on resmetirom. After one year, liver stiffness improved to 10kPa.
"Despite elevated liver enzymes and hepatic steatosis, no testing was done to determine severity nor progression of the disease. Plus, patient was given outdated advice that 'fatty liver' was not something to worry about." —Zobair Younossi, MD, MPH, gastroenterologist & transplant hepatologist, Chairman, Global NASH/MASH Council
Ongoing Management for Later Stages
CASE 2
A 50-year-old woman with type 2 diabetes was referred for mildly elevated ALT. Workup excluded other causes and showed advanced fibrosis with compensated cirrhosis. No therapies initiated. She was counseled on prognosis and nonalcoholic etiology, with lifestyle modification to avoid excess lean-mass loss. Ongoing care includes surveillance for hepatocellular carcinoma, routine monitoring, and, if cirrhosis worsens, transplant options will be considered.
"Sometimes clinicians think you need multiple risk factors to screen. But in a crowd, 1 of 8 would be at risk for significant fibrosis and eligible for treatment. This could be up to 10 patients a week with at-risk fibrosis, or worse.” —Shravan Dave, MD, gastroenterologist & transplant hepatologist, University of California San Diego
Monitor over Time with More Sensitive Tests
CASE 3
A 42-year-old male with a history of dyslipidemia and a BMI of 29 had mild AST/ALT elevation over a course of 7 years. The elevations were low, and typically less than 1.5 times the upper limit of normal. No follow-up was undertaken. At that time, it was noticed that the patient had developed mild thrombocytopenia. A referral to hepatology revealed that the patient had cirrhosis, highlighting that even mild persistent enzyme elevations can signal advanced disease.
“The Fib-4 is a good way to screen in primary care. It is important to note that the fact the elevations in AST and ALT are mild should not be reassuring.
The reason for the AST and ALT elevation is more important than the degree of elevation.” —Wajahat Mehal, MD, PhD, DPhil, gastroenterologist & hepatologist, Director, Yale Fatty Liver Disease Program
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Healthful Living Rx 15
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