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Metabolic dysfunction-associated steatotic liver disease

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Updated 2025 ADA guidelines for the management of metabolic dysfunction-associated steatotic liver disease in patients with type 2 diabetes.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of metabolic dysfunction-associated steatotic liver disease are prepared by our editorial team based on guidelines from the American Association for the Study of Liver Diseases (AASLD 2025,2024,2023), the American Diabetes Association (ADA 2025,2024), the European Association for the Study of Obesity (EASO/EASD/EASL 2024), the European Association for the Study of the ...
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Screening and diagnosis

Indications for screening, adult patients: as per ADA 2025 guidelines, obtain screening for the risk of having or developing cirrhosis related to MASH using a calculated FIB-4 index, even in the presence of normal liver enzymes, in adult patients with T2DM or prediabetes, particularly with obesity or other cardiometabolic risk factors or established CVD.
B
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  • Indications for screening (pediatric patients)

  • Indications for screening (family relatives)

Classification and risk stratification

Noninvasive assessment of fibrosis: as per AASLD 2025 guidelines, obtain simple blood-based noninvasive liver disease assessment tests, such as FIB-4, to detect advanced fibrosis in adult patients with MASLD undergoing fibrosis staging.
B
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Diagnostic investigations

Initial evaluation
As per EASD/EASL/EASO 2024 guidelines:
Obtain evaluation for the potential etiology of steatotic liver disease, alongside tests for the presence of advanced fibrosis, to determine the risk of liver-related and/or cardiovascular outcomes and appropriate care in patients with an incidental finding of steatosis.
B
Recognize that MASLD, ALD, and MASLD with moderate (increased) alcohol consumption are the most common causes of steatotic liver disease, but consider other causes such as drug-induced liver disease and monogenic steatotic liver disease depending on the context.
B
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  • Liver elastography

  • Serum biomarkers

  • Genetic testing

  • Nutritional assessment

  • Screening for comorbidities

Diagnostic procedures

Liver biopsy: as per EASD/EASL/EASO 2024 guidelines, perform liver biopsy for the definite diagnosis of steatohepatitis and to exclude alternative causes of liver disease, but avoid performing it in most cases for the clinical management of MASLD.
A
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Medical management

General principles
As per EASD/EASL/EASO 2024 guidelines:
Insufficient evidence to recommend MASH-targeted pharmacotherapy in adult patients with MASH at the cirrhotic stage.
I
Do not use non-incretin-based weight loss agents as MASH-targeted therapies.
D
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  • Resmetirom

  • Glucose-lowering agents (GLP-1 receptor agonists)

  • Glucose-lowering agents (SGLT-2 inhibitors)

  • Glucose-lowering agents (thiazolidinediones)

  • Glucose-lowering agents (other agents)

  • Other agents

  • Management of clinically significant portal hypertension

  • Management of comorbidities

Nonpharmacologic interventions

Dietary modifications: as per EASD/EASL/EASO 2024 guidelines, advise improving diet quality (similar to the Mediterranean dietary pattern), limiting the consumption of ultra-processed food (rich in sugars and saturated fat), and avoiding sugar-sweetened beverages to improve liver injury in adult patients with MASLD.
B
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  • Weight loss

  • Nutritional support

  • Physical activity

  • Smoking cessation

  • Alcohol restriction

  • Omega-3 fatty acids

  • Vitamin E

  • Probiotics

Therapeutic procedures

Endoscopic procedures: as per EASD/EASL/EASO 2024 guidelines, insufficient evidence to recommend metabolic/bariatric endoscopic procedures as MASH-targeted therapy.
I
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Surgical interventions

Bariatric surgery
As per ADA 2025 guidelines:
Consider offering metabolic surgery as an option for the treatment of MASH and improve cardiovascular outcomes in adult patients with T2DM.
C
Be cautious when offering metabolic surgery in adult patients with T2DM with compensated cirrhosis from MASLD. Do not offer metabolic surgery in patients with decompensated cirrhosis.
B
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  • Liver transplantation (indications)

  • Liver transplantation (pre-transplant evaluation)

  • Liver transplantation (pre-transplant management)

  • Liver transplantation (post-transplant management)

Specific circumstances

Lean patients, screening
As per AGA 2022 guidelines:
Do not obtain routine screening for MASLD in lean persons in the general population.
D
Consider obtaining screening for MASLD in > 40 years old patients with T2DM.
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  • Lean patients (diagnosis)

  • Lean patients (differential diagnosis)

  • Lean patients (risk stratification)

  • Lean patients (noninvasive assessment of fibrosis)

  • Lean patients (imaging)

  • Lean patients (liver biopsy)

  • Lean patients (genetic testing)

  • Lean patients (lifestyle modifications)

  • Lean patients (vitamin E)

  • Lean patients (glucose-lowering agents)

  • Lean patients (surveillance for HCC)

  • Pediatric patients (screening)

  • Pediatric patients (diagnosis)

  • Pediatric patients (management)

  • Pediatric patients (follow-up)

  • Pregnant patients (pre-conception care)

  • Pregnant patients (management during pregnancy)

  • Pregnant patients (breastfeeding)

Preventative measures

Primary prevention: as per EASD/EASL/EASO 2024 guidelines, offer nonpharmacological measures to prevent the development of MASLD and its complications, including HCC, in the general population, and reinforce preventive measures in high-risk groups.
B
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Follow-up and surveillance

Indications for referral: as per AASLD 2023 guidelines, refer patients with suspected advanced MASH or discordant noninvasive tests to a specialist for evaluation, management, and/or further diagnostic evaluation.
E
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  • Laboratory and imaging follow-up

  • Liver biopsy follow-up

  • Surveillance for HCC