Dr Fontana recaps his presentation at Digestive Disease Week 2026 on advances in diagnosis and treatment for patients with MASLD and MASH, and the importance of collaboration among specialties as the numbers of patients with these conditions continues to rise. 

Robert Fontana, MD, is Professor of Medicine and Director of the Transplant Hepatology Fellowship Program at the University of Michigan in Ann Arbor, Michigan.

MASLD/MASH: FDA-Approved Therapies and Noncirrhotic Patient Identification 

• Metabolic dysfunction–associated steatotic liver disease (MASLD)/MASH was highlighted as a growing clinical focus in gastroenterology and hepatology. Dr Fontana noted that steatotic liver disease is now the umbrella term for hepatic steatosis, and that patients with insulin resistance and metabolic syndrome who develop steatosis may be at risk for steatohepatitis and MASH with fibrosis.

• Noncirrhotic MASH patient identification requires multidisciplinary collaboration across primary care, internal medicine, endocrinology, and liver specialists. Dr Fontana described a stepwise approach beginning with imaging evidence of steatosis, followed by fibrosis risk assessment using FIB-4 (age, AST, ALT, and platelet count) and confirmatory vibration-controlled transient elastography to assess liver stiffness and fat burden. Patients with concordant evidence of moderate fibrosis may be referred for intervention because of their risk for progressive fibrosis, cirrhosis, and advanced liver disease.

• Two FDA-approved therapies for noncirrhotic MASH were discussed. Oral resmetirom, a thyroid hormone beta agonist targeting the liver, was reported to reduce inflammation, fat, and fibrosis after 1 year in the MAESTRO studies. Semaglutide received FDA approval following the 72-week ESSENCE study published in the New England Journal of Medicine, demonstrating improvement in MASH and fibrosis resolution versus placebo.

Hi, my name is Bob Fontana. I'm a professor of medicine at the University of Michigan, and I'm joining you here today from DDW in sunny Chicago. It's been a whirlwind meeting, but one of the themes that we're seeing a lot more of is awareness of this clinical entity of MASLD—metabolic dysfunction associated steatotic liver disease—that all of us as gastroenterologists and hepatologists are encountering on a daily basis. As you may know, the nomenclature in this whole field recently changed about two years ago, where we now have an umbrella term called steatotic liver disease, which just means fat in the liver. And then the patients who have insulin resistance and metabolic syndrome who develop steatosis can be at risk to develop steatohepatitis and MASH with fibrosis.

With two FDA-approved treatments, there's a growing interest to identify these patients with noncirrhotic MASH. To do that requires a lot of collaboration. Our goal here is to work together with our primary care colleagues, whether family medicine, internal medicine, endocrine, et cetera, to help triage the patients, if you will. And in the presentation that I'm going to give this afternoon, here at DDW, we're going to walk through those steps.

So as you know, you start usually with an imaging modality that suggests that there's steatosis or fat in the liver. And then you want to know, is this patient having evidence of advanced liver disease or moderately advanced liver disease? And there's some simple tools we have in our kit to do that. The FIB-4, which as you may know, is a combination of age and AST. ALT and platelet count can be calculated in your EMR and tell you whether your patient's low risk or high risk for having advanced fibrosis. I personally like to get a secondary confirmatory test and in our institution we use vibration controlled transient elastography to see how stiff the liver is and how much fat there is. And if those two tests are concordant in suggesting that the patient does have moderate fibrosis, then the algorithms that we're developing and are evolving are to refer those patients for consideration of interventions, because we know those are the patients that are at risk to develop progressive fibrosis, cirrhosis, and all the sequelae of advanced liver disease.

There are currently two FDA-approved therapies, as I mentioned. One of them is called oral resmetirom, which is a thyroid hormone beta agonist that targets the liver. and was shown a couple years ago now in the MAESTRO studies to reduce the amount of inflammation, fat, and fibrosis in the liver after one year of therapy in noncirrhotic patients. And then just this past year, semaglutide, which was already approved for obesity management, diabetes management, and cardiovascular health, was also FDA-approved after a 72-week trial in the New England Journal called the ESSENCE Study that also demonstrated improvement of MASH and resolution of fibrosis compared to placebo.

So now we have two interventions to potentially offer to the proper patients. And I think we as the GI and liver community are going to get busier.

The epidemiology here is quite remarkable. From NHANES, it's estimated there's as many as 30 to 40% of all adults in the United States have steatosis in the liver. And even if it's only 5 to 10% of those, the numbers are staggering, right? Thirty percent of the entire population is about 100 million people. And 5 to 10% of that is 5 to 10 million. So we're all going to have plenty of things to do. And the good news here, particularly at this meeting at DDW, there's a lot of other treatments coming that appear to be even more effective, potentially better tolerated than what we have but it's not all medications and in fact at DDW this year there's some excellent presentations on the evolving role of endobariatrics which you as an endoscopist may learn or someone in your group may learn and that also appears to be quite effective in not only controlling weight but also getting liver benefit from it.

So there's a lot of evolving strategies to treat this tsunami of patients and I think as we all work together in a collaborative care model we'll be able to tackle this and lead to better outcomes for our patients. Thank you.