Ask AI
Back Back
Endo and Primary Care MASH Module

CE / CME

MASH Matters: New Evidence and Its Application to Endocrinology and Primary Care Practice

Physician Assistants/Physician Associates: 0.50 AAPA Category 1 CME credit

Nurse Practitioners/Nurses: 0.50 Nursing contact hour

Physicians: maximum of 0.50 AMA PRA Category 1 Credit™

Released: August 01, 2025

Expiration: July 31, 2026

Kenneth Cusi
Kenneth Cusi, MD, FACP, FACE
CME/CE Information

Activity

Progress
1 2 3
Course Completed

Screening for MASLD/MASH

The screening of patients with MASLD has evolved over the last 5 years. This slide highlights the current guidance that I helped develop with Dr Fasiha Kanwal and Dr Jay Shubrook, among other colleagues. The development of this guidance included experts in hepatology, obesity management, endocrinology, gastroenterology, and primary care.

As you can see, there are 3 high-risk patient groups, those with:

  • 2 or more metabolic risk factors
  • T2D
  • Steatosis on imaging or elevated aminotransferases.

By using the FIB-4 score, healthcare professionals (HCPs) can determine the category in which patients fall, either below 1.3, above 2.67, or between 1.3 and 2.67. These categories further define patients’ risk, with scores higher than 1.3 indicating indeterminate to high risk. The second tier of testing is based on their liver stiffness measurement (LSM) via VCTE.1 The most common device used for this is FibroScan, but there are others like Shearwave that are less broadly utilized in practice. Additional noninvasive testing methods are currently under development.

Download

ADA 2025 Diagnostic Algorithm: Risk Stratification and Cirrhosis Prevention in Patients With MASLD

Here, we have the American Diabetes Association (ADA) diagnostic algorithm for MASLD, which I have been using in my practice for the past couple of years.

There is a question that HCPs first must ask themselves. Does your patient belong to a group that is at the highest risk for developing cirrhosis? That is, do they have T2D, prediabetes (those at a 5%-10% annual risk of developing diabetes), or obesity with 1 or more cardiovascular (CV) risk factor? These risk factors could include prediabetes, T2D, or others like cardiovascular disease (CVD), dyslipidemia, or hypertension.

Now let us focus on the middle of the slide—the FIB-4. When you see patients who fit within any of these 3 at-risk groups, which easily might be two thirds of the patients you see in your clinic, you must determine what their FIB-4 score is. If it is below 1.3, patients have a lower risk of developing future cirrhosis and can be managed by primary care. You also can consider the need for an interprofessional team for these patients, which might involve a weight management expert and the potential to refer to a dietitian, diabetes educator, and others.

Patients whose FIB-4 score is 1.3 or greater are at a higher risk of developing future cirrhosis. Before referring to hepatology, HCPs ideally should order an imaging test (ie, FibroScan) that would determine if patients are at moderate or advanced risk of developing fibrosis. Of note, the FIB-4 is called this because it comprises 4 components: age, aspartate aminotransferase level, alanine aminotransferase level, and platelet count. This score can be inaccurate in patients with portal hypertension and cirrhosis, so it is a rough first step. Despite that nuance, the FIB-4 is a valuable tool because it informs us on how to manage patients based on their risk.1-3

Download

Endocrine Factors Associated With MASLD

There are several risk factors associated with MASLD, with 2—obesity and T2D—already being mentioned. For endocrinology and hepatology, who frequently see patients with liver disease and endocrine conditions, others risk factors associated with MASLD include hypogonadism, polycystic ovary syndrome, hypothyroidism, and growth hormone deficiency.4 These other conditions have not been strongly linked to MASLD and cirrhosis like obesity and T2D have. In addition, hypothyroidism has been linked to MASLD in some studies, but it remains somewhat controversial.

Download

Guideline Recommendations: Who Is at Risk for MASH and Advanced Fibrosis?

All pertinent guidelines have identified T2D as the greatest risk factor for MASH and advanced fibrosis, followed by hypertension and metabolic complications, with prediabetes being the most important. Without getting into the minute details, patients with T2D, prediabetes and obesity, or cardiometabolic risk factors warrant workup.5-7

Download

Commonly Used Noninvasive Tests

There are many noninvasive tests available, with the easiest and most valuable one being the FIB-4. FIB-4 not only identifies patients’ current risk, but the score can be associated with future risk of liver disease as well as CV risk to some extent. There have been efforts to develop other noninvasive tests that do this, but for a practical purpose remember the FIB-4.

There also are some commercial/proprietary tests available, with the enhanced liver fibrosis (ELF) being the first available with a good track record of evidence behind it. The number to remember here is 9.8. If patients’ ELF score is 9.8 or greater, they are at higher risk for developing cirrhosis and should be referred to hepatology. Other tests include the NIS2+ and PRO C3, which are undergoing clinical study for future FDA approval. You should hear more about these tests very soon.

On the imaging side, we already discussed VCTE to detect fibrosis. In addition, there is 2D shear wave elastography and magnetic resonance elastography. The latter is an MRI that uses the same concept of liver stiffness, where the wave detects the degree of stiffness which then correlates with cirrhosis.

Of note, liver fat is not an important parameter other than to diagnose MASLD. Rather, liver fibrosis will define the need for referral to hepatology. Finally, Corrected T1 or Liver MultiScan is a technique that has been used for at least a decade. Studies show that this test measures the degree of inflammation in the liver and fibrosis (also known as fibroinflammation). It has been validated with clinical evidence, and other measurements can be taken with this technique simultaneously. Furthermore, it has a CPT code. Stay tuned, as this is another tool that may become available outside the hepatology realm in the future.8-12

Download

MASLD Fibrosis Score and FIB-4 Score: Online Calculators Easily Interpret Noninvasive Tests

I personally would not use the NAFLD (MASLD) Fibrosis Score (left image) because it over diagnoses fibrosis. This is why the FIB-4 is now favored in clinical practice. But how do you calculate a FIB-4 score? You can easily search for "FIB-4 calculator" on your phone or in your electronic health record (EHR). In some EHRs like Epic, you can type ".FIB-4" and it will calculate the FIB-4 score in your medical notes or templates.

There are a couple of caveats regarding the FIB-4. One is that it is an inexpensive test. You can have it embedded in your EHR, but you should not use it for all patients. This is a learning curve for many HCPs. Second, do not use the FIB-4 for patients younger than 35 years, because it will underestimate their risk. In addition, in patients older than 65 years, HCPs should consider a higher cutoff; at least 1.6 with some literature stating 2.0 is ideal. The important thing to remember is that sometimes you must rely on your own clinical criteria. For example, if patients with obesity and diabetes have a FIB-4 higher than 1.3, you should complete a second test. If older patients have a high FIB-4 but no risk factors, that is probably an overread, which happens in a significant number of people. This is something that HCPs should keep in mind moving forward.13,14

Download
BACK | NEXT