Gastroenterology · AASLD

MASLD / non-alcoholic fatty liver disease

AASLD

Source:AASLD Practice Guidance: Clinical Assessment and Management of NAFLD/MASLD (2023, with 2024 nomenclature update)EASL-EASD-EASO MASLD CPG 2024

Verified Apr 2026

Ask House about this guideline

Red Flags

MASLD with FIB-4 ≥2.67 or transient elastography ≥12 kPa — advanced fibrosis (F3/F4); hepatology referral and HCC surveillance^[1]
Decompensated cirrhosis (ascites, variceal bleed, encephalopathy) — admit; hepatology and consider transplant evaluation^[1]
Alcohol use disorder concurrent with MASLD — manage as MetALD or alcohol-associated liver disease per CAGE/AUDIT screen; alcohol cessation transformative^[1]
Suspected HCC on surveillance — multiphasic CT or MRI; hepatobiliary multidisciplinary meeting^[1]

First-line treatment

Interventions

Weight reduction 7–10% via lifestyle modification^[1]
Cornerstone treatment; ≥7% weight loss reverses steatohepatitis, ≥10% reduces fibrosis. Mediterranean diet, physical activity ≥150 min/week
Bariatric surgery^[1]
Selected obese patients with MASH; sustained weight loss reverses steatohepatitis and fibrosis in many; multidisciplinary team
HCC surveillance for cirrhotics^[1]
Ultrasound + AFP every 6 months for compensated cirrhosis; non-cirrhotic high-risk MASH (PNPLA3 risk variant, family history) per local protocol

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Resmetirom^[1]	Selective thyroid hormone receptor-β agonist	80–100 mg PO once daily (weight-based)	—	First FDA-approved MASLD therapy (2024); for biopsy-confirmed MASH with significant or advanced fibrosis (F2-F3); MAESTRO-NASH trial
Semaglutide or tirzepatide (in DM or obesity)^[1]	GLP-1 / GIP-GLP-1 receptor agonist	Semaglutide 2.4 mg SC weekly (Wegovy); tirzepatide 5–15 mg SC weekly (Mounjaro)	—	MASLD with concurrent T2DM or obesity; weight loss-mediated steatohepatitis improvement; ESSENCE trial demonstrated histologic benefit with semaglutide
Pioglitazone^[1]	Thiazolidinedione	30 mg PO once daily	—	Selected biopsy-confirmed MASH (with or without DM); weight gain and fluid retention concerns; avoid in HF
Vitamin E^[1]	Antioxidant	800 IU PO daily	—	Selected non-diabetic biopsy-confirmed MASH; small risk of haemorrhagic stroke and prostate cancer (long-term)
Statin therapy (cardiovascular indication)^[1]	HMG-CoA reductase inhibitor	Per cardiovascular risk	—	Statins safe in MASLD including compensated cirrhosis; reduce CV mortality which is the leading cause of death in MASLD

Resmetirom^[1]

Selective thyroid hormone receptor-β agonist

Adult: 80–100 mg PO once daily (weight-based)
Paediatric: —

First FDA-approved MASLD therapy (2024); for biopsy-confirmed MASH with significant or advanced fibrosis (F2-F3); MAESTRO-NASH trial

Semaglutide or tirzepatide (in DM or obesity)^[1]

GLP-1 / GIP-GLP-1 receptor agonist

Adult: Semaglutide 2.4 mg SC weekly (Wegovy); tirzepatide 5–15 mg SC weekly (Mounjaro)
Paediatric: —

MASLD with concurrent T2DM or obesity; weight loss-mediated steatohepatitis improvement; ESSENCE trial demonstrated histologic benefit with semaglutide

Pioglitazone^[1]

Thiazolidinedione

Adult: 30 mg PO once daily
Paediatric: —

Selected biopsy-confirmed MASH (with or without DM); weight gain and fluid retention concerns; avoid in HF

Vitamin E^[1]

Antioxidant

Adult: 800 IU PO daily
Paediatric: —

Selected non-diabetic biopsy-confirmed MASH; small risk of haemorrhagic stroke and prostate cancer (long-term)

Statin therapy (cardiovascular indication)^[1]

HMG-CoA reductase inhibitor

Adult: Per cardiovascular risk
Paediatric: —

Statins safe in MASLD including compensated cirrhosis; reduce CV mortality which is the leading cause of death in MASLD

Safety-net

Weight loss is the most powerful treatment — even 5% reverses some damage; sustained 10% reverses fibrosis in many^[1]
Avoid alcohol — even moderate amounts accelerate MASLD progression^[1]
Watch for fatigue worsening, swelling, easy bruising, vomiting blood, or yellow eyes — call clinician same day (cirrhosis decompensation)^[1]

Referral criteria

FIB-4 ≥2.67 or transient elastography ≥12 kPa (advanced fibrosis)Hepatology^[1]
Decompensated cirrhosisHepatology and transplant centre^[1]
Biopsy-confirmed MASH with F2–F3 fibrosis considering resmetiromHepatology specialist^[1]
BMI ≥35 with MASH considering bariatric surgeryMultidisciplinary obesity / bariatric service^[1]

Clinical summary

Diagnosis and stratified management of MASLD (formerly NAFLD/NASH) with FIB-4 risk-stratification and resmetirom for advanced fibrosis.

References

1.AASLD Practice Guidance: Clinical Assessment and Management of NAFLD/MASLD (2023, with 2024 nomenclature update); EASL-EASD-EASO MASLD CPG 2024 (2024)

Drug

Class

Adult

Paediatric

Notes