Guidance
Plain summaries of international guidelines, sorted by topic. We summarise; we do not write new guidelines.
The fibrosis pathway in four steps
For adults with MASLD or at risk of it. Summarised from the EASL–EASD–EASO 2024 clinical practice guideline.
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Find people at risk
Type 2 diabetes, abdominal obesity with at least one other metabolic risk factor, or persistently raised liver enzymes.
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Calculate FIB-4
Below 1.3: low risk; manage metabolic risk and re-check in 1 to 3 years. 1.3 or above: go to step 3. Open the calculator.
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Measure liver stiffness
Transient elastography (VCTE), or ELF if not available. Below 8 kPa: low risk, stay in primary care. 8 to 12 kPa: indeterminate. 12 kPa or above: advanced fibrosis likely.
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Refer to a liver specialist
Indeterminate or high results go to hepatology for full assessment, treatment decisions and, when needed, cancer surveillance.
Source: EASL–EASD–EASO Clinical Practice Guidelines on the management of MASLD. J Hepatol 2024;81:492–542.
By topic
Diagnosis and non-invasive tests
Definitions, the four-step pathway, cut-offs.
Lifestyle
Weight-loss targets, diet quality, activity, alcohol.
Drugs
Approved MASH medicines, metabolic drugs, and the pipeline.
Bariatric and endoscopic options
Who benefits, and what to check first.
Heart and metabolic risk
The heart is the main threat in most patients.
Special groups
Lean MASLD, MetALD, older adults, pregnancy, children.
Lifestyle: the base of every treatment plan
Every patient with MASLD needs a lifestyle plan, with or without medicines.
| Weight loss | What it does to the liver |
|---|---|
| ≥ 5% | Less liver fat |
| 7–10% | Less inflammation; MASH can resolve |
| ≥ 10% | Fibrosis can improve |
Food
- A Mediterranean-style pattern: vegetables, legumes, whole grains, fish, olive oil, nuts.
- Cut sugary drinks and juices, sweets, white bread and white rice.
- Limit ultra-processed foods and fried food.
- Gulf tip: swap kabsa white rice for a smaller portion with salad first; dates in small numbers.
Activity, alcohol and smoking
- At least 150 minutes a week of moderate activity (for example brisk walking), or 75 minutes of vigorous activity.
- Add resistance exercise twice a week. Exercise helps the liver even without weight loss.
- Reduce alcohol; stop completely if there is advanced fibrosis or cirrhosis.
- Stop smoking: it adds to heart and liver cancer risk.
Patient versions: printable one-page guides.
Drugs
Two medicines are now approved for MASH with moderate-to-advanced fibrosis (F2–F3) without cirrhosis. Both are add-ons to lifestyle change, not replacements. Approval in Saudi Arabia and other Gulf countries should be checked locally.
| Medicine | How it works | Approvals for MASH |
|---|---|---|
| Resmetirom | Oral, once daily. Activates the liver's thyroid hormone receptor-β to burn liver fat. | US FDA, March 2024 (accelerated) · European Commission, August 2025 (conditional) · UK MHRA, June 2026 |
| Semaglutide 2.4 mg | Weekly injection. GLP-1 receptor agonist: weight loss and better metabolic control. | US FDA, August 2025 (accelerated) · UK MHRA, July 2026 (conditional) |
Metabolic drugs with liver benefit
- GLP-1 agonists and tirzepatide: first choice when MASLD comes with type 2 diabetes or obesity.
- SGLT2 inhibitors: protect heart and kidneys; safe in MASLD.
- Pioglitazone: can help MASH in people with type 2 diabetes; watch weight gain and fluid retention.
- Statins are safe in MASLD, including compensated cirrhosis. Do not stop them because of raised liver enzymes.
The pipeline to watch
- FGF21 analogues (efruxifermin, pegozafermin): in phase 3 trials, including patients with cirrhosis.
- GLP-1 combinations (with glucagon or GIP): in late-stage trials.
- Outcome trials for the approved drugs are due from 2027, to show they prevent cirrhosis and liver events.
Bariatric and endoscopic options
Metabolic (bariatric) surgery
- Consider it for people with MASLD and obesity who meet the usual surgery criteria.
- It can resolve MASH and improve fibrosis in many patients.
- Before surgery, stage the liver. Cirrhosis, and especially portal hypertension, raises surgical risk and needs a specialist centre.
Endoscopic options
- Intragastric balloon and endoscopic sleeve gastroplasty lower weight with less invasion.
- Liver data are promising but smaller than for surgery.
- They can bridge to surgery or suit people who decline it.
Heart and metabolic risk
Most people with MASLD are more likely to die from heart disease than from liver disease. Every liver visit is also a heart visit.
Check
Blood pressure, HbA1c, full lipid profile, kidney function and urine albumin, weight and waist.
Look deeper
ApoB is more reliable than LDL when triglycerides are high. Consider measuring Lp(a) once in life.
Treat to target
Use statins and blood-pressure drugs as for anyone at the same heart risk. Choose diabetes drugs that also protect the heart.
Special groups
| Group | What is different |
|---|---|
| Lean MASLD | Normal BMI does not rule it out. Assess fibrosis the same way. Aim for 3–5% weight loss and more activity. |
| MetALD | Metabolic risk plus moderate alcohol (140–350 g a week in women, 210–420 g in men). Alcohol speeds damage, so ask about it carefully and advise cutting down or stopping. |
| Age 65 and over | Use a FIB-4 cut-off of 2.0 instead of 1.3 to avoid false alarms. |
| Pregnancy | MASLD raises the risk of gestational diabetes and pre-eclampsia. Do not aim for weight loss or start MASH drugs during pregnancy; plan before conception. |
| Children and teenagers | FIB-4 is not validated. Refer to paediatric gastroenterology and involve the whole family in lifestyle change. |
Sources
- EASL–EASD–EASO Clinical Practice Guidelines on the management of MASLD. J Hepatol 2024;81:492–542.
- Rinella ME, et al. AASLD Practice Guidance on the clinical assessment and management of NAFLD. Hepatology 2023;77:1797–835.
- Rinella ME, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. J Hepatol 2023.
- Madrigal Pharmaceuticals. European Commission approval of Rezdiffra, 19 August 2025. Press release
- British Liver Trust. Two MASH treatments receive MHRA approval, 2026. News
- HCPLive. MASH pipeline developments to watch in 2026, January 2026. Interview
How we review evidence
- We start from current guidelines (EASL, AASLD, AACE) and major trials.
- Every page shows a "last reviewed" date and its sources.
- Each page is reviewed at least once a year, and sooner when guidance changes.
- Sponsors never write or approve content. Read our policy.
Last updated
| Date | Change |
|---|---|
| 2026-10-02 | Added lifestyle, drugs, bariatric and endoscopic options, heart risk, and special groups. |
| 2026-10-02 | Site launched; fibrosis pathway published. |
Questions about our guidance
Is this a new guideline?
No. We summarise published international guidance in plain words and point to the source.
Can I suggest a topic?
Yes. Email mdesoky15@gmail.com with the topic and why it matters in your practice.