Synopsis
Identify metabolic dysfunction-associated steatotic liver disease, stratify fibrosis rather than relying on enzymes, and reduce liver and cardiovascular risk through coordinated care.
- MASLD describes hepatic steatosis in a person with cardiometabolic risk after other major causes are assessed; metabolic and alcohol-related injury can coexist.
- Type 2 diabetes, central adiposity, dyslipidaemia, hypertension, obstructive sleep apnoea and polycystic ovary syndrome increase risk, but lean people can also develop advanced disease.
- Normal ALT does not exclude steatohepatitis or advanced fibrosis, and the degree of ultrasound brightness does not stage scarring.
- The key prognostic task is fibrosis assessment using the current commissioned pathway, not repeated routine liver panels alone.
- As of August 2026, NICE NG49 and newer BSG-endorsed ELF guidance use different advanced-fibrosis cut-offs; apply the locally adopted threshold and do not mix algorithms.
- FIB-4 can be a first step in some pathways but is unreliable in younger adults, acute illness and some older age groups; indeterminate or high results need a second-line test.
- Lifestyle treatment should be specific and supported: sustained weight reduction, Mediterranean-style eating, reduced sugary drinks, regular aerobic and resistance activity, sleep and alcohol review.
- Cardiovascular disease is a major cause of harm, so optimise blood pressure, lipids, glycaemia, smoking and obesity alongside liver care; statins are not routinely withheld because of stable MASLD.
- Advanced fibrosis or cirrhosis triggers hepatology referral, portal-hypertension assessment and surveillance for hepatocellular carcinoma under the current cirrhosis pathway.
Key red flags
Thrombocytopenia, splenomegaly, low albumin, prolonged INR, palmar erythema or a high non-invasive fibrosis result suggests portal hypertension or cirrhosis even when ALT is normal.
Ascites, variceal bleeding, jaundice, encephalopathy or renal dysfunction indicates cirrhosis complications and needs urgent structured assessment, not a routine lifestyle-only appointment.
Investigation priorities
Establish cardiometabolic drivers and identify combined aetiology.
Provide inexpensive initial fibrosis triage in commissioned two-step pathways.
Management branches
Imaging-detected fat, persistent transaminitis or high-risk metabolic disease.
- Confirm metabolic risk, quantify alcohol and review medicines, viral exposure, family history and features of autoimmune or inherited disease; examine for chronic liver signs.
- Obtain a complete liver panel, blood count, metabolic measures and recommended aetiology screen rather than assuming every raised ALT in obesity is MASLD.
- Enter the locally commissioned fibrosis pathway using ELF directly or a validated first-line score followed by ELF or elastography, documenting the specific cut-offs used.
- Refer advanced, discordant or unexplained results to hepatology; return low-risk disease to planned metabolic and fibrosis reassessment rather than discharging permanently.
Key medicines
Statin therapyChoose intensity and dose from the current NICE cardiovascular-risk and lipid pathway.Stable MASLD is not a routine contraindication. Obtain baseline liver tests and follow current stopping rules for unexplained marked enzyme rise, muscle symptoms, interactions or decompensated cirrhosis.
GLP-1 receptor agonist or dual incretin therapyUse only for an approved diabetes or weight-management indication and titrate by protocol.Do not present as universally licensed liver treatment. Review gastrointestinal effects, pancreatitis or gallbladder history, renal status, pregnancy plans and product-specific supply and eligibility guidance.