GHAPPcast: Recognizing the Severity of MASH

Thank you to Madrigal for your support of this GHAPPcast episode.

In this GHAPPcast episode, Patrick Horne, NP, from the University of Florida, and April Morris, NP, from Richmond VA, discuss how to recognize the severity of MASH, identify at-risk patients, and implement early intervention strategies to prevent disease progression.

MASH is strongly linked to metabolic dysfunction, making certain populations more vulnerable to developing the disease. Some of the key risk factors include type 2 diabetes, obesity, hypertension, and high cholesterol. Family history also plays a crucial role, as many patients with MASH have relatives who have experienced early heart attacks, strokes, or diabetes. As Patrick Horne, NP, points out, genetic predisposition often contributes to metabolic diseases, making a detailed family history essential for identifying at-risk individuals.

One of the biggest challenges in MASH management is that liver enzyme levels (ALT, AST) do not always indicate disease severity. Many patients with advanced fibrosis or cirrhosis can have completely normal liver function tests, leading to missed diagnoses. To accurately stage MASH and assess fibrosis risk, providers should rely on non-invasive liver assessments in addition to bloodwork. Tools like the FIB-4 Score, FibroScan, MRI Elastography (MRE), and ultrasound help stratify risk, guide treatment decisions, and reduce the need for liver biopsy in many cases.

While pharmacologic treatment for MASH has recently emerged, lifestyle modification remains the foundation of management. Healthcare providers should emphasize dietary changes and exercise to slow MASH progression. The Mediterranean diet is often recommended due to its benefits in liver and metabolic health. Increasing intake of vegetables, lean proteins, and fiber-rich foods while reducing processed foods and sugar-sweetened beverages is key. Exercise is equally critical, as regular physical activity helps reduce liver fat, improve insulin sensitivity, and lower cardiovascular risk. One simple but effective intervention is eliminating sugar-sweetened beverages, such as sodas and energy drinks, which can significantly contribute to liver fat accumulation.

Until recently, there were no FDA-approved medications for MASH, but in March 2024, the FDA approved Resmetirom as the first therapy for non-cirrhotic MASH with moderate to advanced fibrosis (F2-F3). Resmetirom is a thyroid hormone receptor beta (THR-β) selective agonist that targets liver fat metabolism, inflammation, and fibrosis progression. Clinical trials have shown that Resmetirom significantly improves MASH resolution and reduces fibrosis progression, making it a breakthrough therapy for patients at risk of cirrhosis. However, insurance coverage varies, and providers may need to assist with prior authorizations to ensure patient access to treatment.

Once a patient is diagnosed with MASH, regular follow-up and monitoring are essential. For those started on medication therapy, providers typically schedule follow-up visits every 4-6 weeks to evaluate symptoms and ensure medication adherence. Lab work and imaging studies (FibroScan, MRI elastography) may also be used to track treatment response and liver fibrosis progression over time. Weight loss goals should be individualized, but even a 7-10% reduction in body weight has been shown to significantly improve liver health. Patients should be encouraged to approach weight loss gradually, as rapid weight loss can actually worsen liver disease.

MASH is a serious yet manageable disease that requires early recognition, metabolic risk assessment, and proactive intervention. With the availability of new non-invasive diagnostics and FDA-approved treatments, providers now have more tools than ever to improve patient outcomes and reduce the burden of MASH-related liver disease. By emphasizing early detection, lifestyle interventions, and personalized treatment strategies, healthcare providers can help patients mitigate their risk of fibrosis progression and improve overall metabolic health.

For more expert discussions on MASH diagnosis, treatment, and liver disease management, visit the GHAPP website or download the GHAPP ACE app.