Synopsis
Recognise clustered cardiometabolic risk without diagnostic shorthand, identify metabolic steatotic liver and advanced fibrosis, and treat each modifiable vascular and hepatic driver.
- Metabolic syndrome describes central adiposity, dysglycaemia, raised blood pressure and atherogenic lipids clustering through insulin resistance; treat the components rather than relying on the label.
- NICE now uses metabolic dysfunction-associated steatotic liver disease terminology in NG49, while local records and evidence may still say NAFLD; document what diagnostic criteria were used.
- MASLD ranges from steatosis through inflammatory injury and fibrosis to cirrhosis and liver cancer; fibrosis stage, not transaminase height, drives liver prognosis.
- Normal ALT and AST do not exclude steatotic liver or advanced fibrosis, and abnormal tests alone do not establish its cause.
- Assess alcohol sensitively and quantitatively because metabolic and alcohol-related injury can coexist; do not use body size to dismiss harmful alcohol exposure.
- An incidental fatty liver on imaging should trigger diabetes, blood pressure, lipid, medication and fibrosis-risk assessment rather than reassurance or automatic hepatology referral.
- For adults with diagnosed MASLD, NICE recommends enhanced liver fibrosis testing to identify advanced fibrosis rather than using routine liver tests as the fibrosis screen.
- An ELF score of 10.51 or above indicates advanced fibrosis in the NICE pathway and warrants specialist liver assessment; below threshold requires periodic reassessment.
- Statins are generally safe and important for vascular risk in MASLD; NICE only considers stopping if transaminases double within three months of starting.
- Weight management, physical activity, glycaemic care, blood pressure treatment, lipid lowering, sleep-apnoea care and smoking cessation form the core treatment package.
- People with cirrhosis need hepatology-led variceal, hepatocellular carcinoma, nutrition, vaccination and decompensation surveillance beyond a primary metabolic review.
Key red flags
Ascites, jaundice, variceal bleeding, encephalopathy, sarcopenia or hepatorenal dysfunction indicates advanced disease and requires urgent or expedited hepatology depending on physiological stability.
Investigation priorities
Document central adiposity and a major treatable vascular component.
Refine fibrosis, portal-hypertension and cirrhosis risk after an abnormal first-line test.
Management branches
Central adiposity or dysglycaemia suggests clustered cardiometabolic risk.
- Measure pressure, HbA1c, lipids, adiposity, smoking, sleep and liver context, and ask about cardiovascular symptoms, medicines, alcohol and family history.
- Use separate NICE thresholds to treat hypertension, diabetes, lipids and obesity, agreeing practical nutrition, activity, sleep and smoking goals without depending on a syndrome label.
- Schedule integrated review of all targets and medicine burden, escalating to relevant specialists when vascular, respiratory, renal or liver complications emerge.
Key medicines
Atorvastatin for cardiovascular prevention in MASLDUse the NICE indication-based oral dose, commonly 20 mg once daily for eligible primary prevention or 80 mg once daily for secondary prevention, adjusted for interactions and tolerability.Fatty liver alone is not a contraindication. Check baseline transaminases and the current BNF; NICE suggests considering cessation if liver enzymes double within three months, while pregnancy and severe active liver disease need specialist review.
Pioglitazone in specialist-selected advanced fibrosisUse only an endocrinology or hepatology-selected once-daily regimen within the current NICE and diabetes context after discussing uncertain liver benefit and patient-specific risks.Can cause weight gain, oedema, heart failure, fractures and other adverse effects; review bladder history, pregnancy and liver function. Do not prescribe solely for an incidental fatty ultrasound in primary care.