ADA 2025 Guidelines- Management of MASLD

ADA 2025 Guidelines- Management of MASLD:
Before initiating the pharmacological treatment for MASLD, the guidelines emphasize the importance of individualized care targeting these five areas:

1. Adoption of a healthy lifestyle: This is the foundation of MASLD management and includes dietary changes (reducing calorie intake, focusing on whole foods, limiting processed foods and sugary drinks), regular exercise, and addressing other lifestyle factors like sleep and stress management.
2. Weight loss (if indicated): Weight loss is especially important for individuals with overweight or obesity, as it can significantly improve liver health.
   The guideline recommends a weight loss of at least 5% for improving steatosis and ≥10% for improving fibrosis.
3. Optimal diabetes management: If the patient has diabetes, achieving good glycemic control is crucial, as it influences both liver health and overall metabolic health. This involves appropriate medication, blood glucose monitoring, and lifestyle adjustments.
4. Cardiovascular risk reduction: Given the strong link between MASLD and cardiovascular disease, managing risk factors like hypertension, dyslipidemia, and smoking is essential.
5. Need for metabolic surgery (as recommended by guidelines): Bariatric surgery may be considered for individuals with severe obesity and MASLD who meet specific criteria. This is a more aggressive intervention but can lead to substantial weight loss and metabolic improvement.

These five components highlight the approach to MASLD management before starting the pharmacological treatment.
This table summarizes the treatment algorithm, the recommended pharmacotherapy based on the patient's MASLD stage and the presence of obesity or diabetes. It also emphasizes the caution needed when treating patients with compensated cirrhosis. Remember to always consult the full guideline for complete details and context:

 

 

 

 

 

 

MASLD Stage	Obesity Pharmacotherapy	Diabetes Pharmacotherapy	Metabolic Dysfunction-Associated Steatohepatitis (MASH) Pharmacotherapy
MASLD with F0-F1	GLP-1 RA, dual GIP and GLP-1 RA preferred.	GLP-1 RA, dual GIP and GLP-1 RA, pioglitazone, SGLT2i preferred.	Not indicated
MASLD with F2-F3<br>("at risk" MASH)	GLP-1 RA, dual GIP and GLP-1 RA preferred.	GLP-1 RA, dual GIP and GLP-1 RA, pioglitazone preferred.	Resmetirom
Compensated Cirrhosis	Same as F2-F3, but with caution.*	Same as F2-F3, but with caution.*	AVOID
Decompensated Cirrhosis	AVOID	Only use insulin	AVOID

 

 

*Individualized care and close monitoring are needed in compensated cirrhosis given limited safety data.

Key:

• F0-F1: No to minimal fibrosis
• F2-F3: Moderate fibrosis
• F4: Cirrhosis (Compensated or Decompensated)
• GLP-1 RA: Glucagon-like peptide-1 receptor agonist
• GIP: Glucose-dependent insulinotropic polypeptide
• SGLT2i: Sodium-glucose cotransporter-2 inhibitor
• MASH: Metabolic dysfunction-associated steatohepatitis (previously NASH)

Reference:
ADA 2025 Guidelines Section 4
To access the full guidelines:
ADA Guidelines – Standards of care in Diabetes 2025

 MASLD: Metabolic Dysfunction-Associated Statotic Liver Disease