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      Metabolic Dysfunction Associated Steatohepatitis

      Brief Overview: According to Cedars-Sinai, “Metabolic dysfunction-associated steatohepatitis (MASH) is an advanced form of metabolic dysfunction-associated steatotic liver disease (MASLD). MASLD is caused by buildup of fat in the liver. When this buildup causes inflammation and damage, it is known as MASH, which can lead to scarring of the liver.”

      Prevalence: The prevalence of MASH is estimated to be ~ 1.5-6.5% of US adults.

      Etiology: According to UpToDate, “The cause of MASH is metabolic dysfunction seen in people with certain medical conditions such as insulin resistance (prediabetes or diabetes), high blood pressure, high cholesterol, and/or obesity. This combination of disorders is often called "metabolic syndrome."

      Risk Factors:

      • Overweight, obese
      • Diabetes
      • Dyslipidemia
      • HTN
      • Metabolic syndrome

      Commonly Associated Conditions:

      • Type 2 diabetes
      • Dyslipidemia
      • Obesity
      • Metabolic syndrome
      • Hypothyroidism

      Common Medications:

      • No medications have been approved to treat MASH, but there are some medications used for a targeted approach:
        • Resmetirom – for patients with MASH and fibrosis stage F2 or F3 who do not achieve sustained weight loss. This is still being studied
        • Vitamin E – for patients with biopsy-proven MASH and fibrosis stage 2 or greater without diabetes. Do not take Vitamin E unless directed to do so by your healthcare provider.
        • Pioglitazone in patients with biopsy-proven MASH and diabetes
        • Weight loss medication, if indicated – GLP-1 (semaglutide, liraglutide)

      Common Labs, Imaging, and Tests:

      • Imaging: abdominal ultrasound, MRI
      • Liver biopsy
      • Transient elastography
      • FibroScan
      • Lab tests: CMP, lipid panel, HgbA1c, CBC

      Common Symptoms:

      • Typically, asymptomatic
      • Fatigue, malaise
      • Upper abdominal discomfort

      Common Treatments:

      • According to UpToDate, “Treatment of MASH focuses on weight loss, controlling some of the medical conditions associated with MASH (such as diabetes and obesity), and monitoring for progression”
      • Medications (see above)
      • Weight loss, if indicated
      • Management of any associated conditions

      Physical Findings:

      • Typically, normal physical exam
      • Hepatomegaly may be present

      Potential Complications and Contraindications:

      • May progress to cirrhosis
      • Liver failure
      • Liver cancer
      • Cardiovascular disease

      General Health and Lifestyle Guidance:

      • Avoid alcohol
      • Talk to your healthcare provider before taking any OTC supplements or vitamins
      • Exercise as directed by your healthcare provider
      • Consume a healthy diet and follow any dietary recommendations advised by your healthcare provider/dietician
      • Work with your healthcare provider to achieve and maintain control of any associated conditions 
      • Stay up to date on all age-appropriate vaccinations (Hep A, Hep B, flu vaccine, pneumonia vaccine, Tdap, shingles vaccine, etc.). Talk to your healthcare provider about what vaccines are recommended for you. 

      Suggested Questions to Ask Patients:

      • Have you been told you have fatty liver or abnormal liver enzymes?
      • Are you currently managing diabetes, weight, or cholesterol?
      • Have you experienced fatigue or right upper quadrant discomfort?
      • Have you had imaging, labs, or a liver biopsy recently?

      Suggested Talking Points:

      • Make sure to go to all follow-up appointments. Complete all blood work and any other tests ordered by your healthcare provider
      • Consider working with a dietician if this is available to you

      Sources: