MASLD / non-alcoholic fatty liver disease

Red Flags

MASLD with FIB-4 ≥2.67 or transient elastography ≥12 kPa — advanced fibrosis (F3/F4); hepatology referral and HCC surveillance^[1]
Lean MASLD (BMI <25) with metabolic risk factors — does not exclude advanced disease; investigate fully and screen for genetic predisposition (PNPLA3)^[1]
Decompensated cirrhosis — admit; hepatology and transplant evaluation^[1]
Suspected HCC on surveillance — multiphasic CT or MRI; hepatobiliary multidisciplinary meeting^[1]

Weight reduction 7–10% via lifestyle modification^[1]
Cornerstone treatment; ≥7% weight loss reverses steatohepatitis, ≥10% reduces fibrosis. Mediterranean-style diet adapted to local food culture, physical activity ≥150 min/week
Address metabolic syndrome^[1]
Treat T2DM with kidney/cardio-protective agents (SGLT2 inhibitor, GLP-1 RA), hypertension, dyslipidaemia (statin); smoking cessation; alcohol abstinence; address sleep apnoea
Lean MASLD pathway^[1]
Indian populations and South Asians have higher MASLD risk at lower BMI; lean MASLD (BMI <25) requires same metabolic and fibrosis assessment; not less serious
Bariatric surgery^[1]
Selected obese patients with MASH; sustained weight loss reverses steatohepatitis and fibrosis; 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

Drug	Class	Adult	Paediatric	Notes
Semaglutide or tirzepatide (DM or obesity)^[1]	GLP-1 / GIP-GLP-1 receptor agonist	Semaglutide 2.4 mg SC weekly (Wegovy); tirzepatide 5–15 mg SC weekly	—	MASLD with concurrent T2DM or obesity; weight-loss-mediated steatohepatitis improvement; ESSENCE trial confirmed histologic benefit with semaglutide
Pioglitazone^[1]	Thiazolidinedione	30 mg PO once daily	—	Selected biopsy-confirmed MASH; weight gain and fluid retention concerns; avoid in heart failure; lower cost option
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^[1]	HMG-CoA reductase inhibitor	Per cardiovascular risk	—	Statins safe in MASLD including compensated cirrhosis; reduce CV mortality (leading cause of death in MASLD)

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

GLP-1 / GIP-GLP-1 receptor agonist

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

Pioglitazone^[1]

Thiazolidinedione

Selected biopsy-confirmed MASH; weight gain and fluid retention concerns; avoid in heart failure; lower cost option

Vitamin E^[1]

Antioxidant

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

Statin therapy^[1]

HMG-CoA reductase inhibitor

Statins safe in MASLD including compensated cirrhosis; reduce CV mortality (leading cause of death in MASLD)

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 progression in MASLD^[1]
Watch for fatigue worsening, swelling, easy bruising, vomiting blood, or yellow eyes — call clinician same day (cirrhosis decompensation)^[1]

FIB-4 ≥2.67 or transient elastography ≥12 kPa (advanced fibrosis)Hepatology^[1]
Decompensated cirrhosisHepatology and transplant centre^[1]
Lean MASLD with metabolic risk factorsHepatology and endocrinology for joint workup^[1]
BMI ≥35 with MASH considering bariatric surgeryMultidisciplinary obesity / bariatric service^[1]

Diagnosis and stratified management of MASLD/NAFLD with emphasis on lean phenotype and metabolic risk in adults.

1.INASL Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (2023) (2023)