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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

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Multidisciplinary Care Advances the Treatment of Patients With MASH

I want to highlight an important component of MASLD/MASH management: the need for multidisciplinary or interprofessional teams.

The ADA, in its multidisciplinary approach, has summarized what all HCPs need to know in the figure on the slide. First is weight loss, as we have already discussed. Losing 7% to 10% of one’s total body weight is needed to reverse steatohepatitis and fibrosis. Do note that there is a lot of variability in that. This ability to reverse steatohepatitis or fibrosis with weight loss also depends on the quality of patients’ food and the amount of physical activity they do. So take this as an indicator, but it needs to be reviewed in greater depth in future studies.

Regarding nutrition, remember the Mediterranean diet, low-calorie options, and that patients need a negative caloric balance. They also should avoid what we call junk food and soda. It is also important to educate patients about diabetes, including self-management strategies. Patients should also be instructed to increase their physical activity to at least 150 minutes a week.

I have not yet mentioned that excess alcohol is very damaging for patients with T2D and obesity. Furthermore, it has a synergistic effect in damaging the liver. HCPs should tell patients to abstain from alcohol if they have moderate to severe fibrosis; this message is critical. Although recent guidance has mentioned that any amount of alcohol is bad for patients’ health, regardless of whether they have liver disease, 1 serving a day probably has a modest effect. This is something to consider.

Finally, behavioral health overall is a necessary component of MASLD/MASH management.2

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Summary of Updates at ACCE, ADA, and ENDO

If you take together the American Association for Clinical Endocrinologists, ADA, and the Endocrine Society’s annual meetings this year, they said the same thing: early identification and risk stratification of MASLD/MASH is the name of the game.

These 3 organizations agree that we need to routinely consider doing a FIB-4 test for all our patients with T2D, prediabetes, or obesity with cardiometabolic risk factors. After the FIB-4 test, HCPs should order an LSM or ELF to confirm patients’ status. Noninvasive testing is rapidly evolving, and much is going to change over the next year or 2 as more tests are becoming available and validated.

Develop your network of HCPs who are going to help you. Help your hepatologists get their patients early on by getting trained and learning which patients are the priority for referral. HCPs should not refer patients because they have fat in their liver (or steatosis); rather, they should be referred if they have moderate to advanced fibrosis, meaning their FIB-4 score is 1.3 or greater or their LSM score is 8 or greater.

Lifestyle changes and education should be something that you are working on with patients on a daily basis. Pharmacotherapy for weight loss with GLP-1 receptor agonists or dual GIP/GLP-1 receptor agonist and for diabetes with pioglitazone is important. Note that pioglitazone 15 mg does not really cause weight gain. If any, it is 1% or 1 kg in somebody who is 80 kg or greater. After starting with this lower dose, HCPs can increase it to 30 mg, which may reverse steatohepatitis and improve fibrosis in some patients with diabetes.

Remember to consider a referral to pathology when patients’ FibroScan and FIB-4 scores are increased. In addition, hepatology has access to magnetic resonant elastography, Liver MultiScan, and other biomarkers, and they will help you get patients on resmetirom if indicated.

Many new agents are emerging, so stay tuned. This field is going to get crowded with new agents soon. From my point of view, HCPs should optimize any weight loss and glucose-lowering therapies for those with obesity and/or T2D because these agents will be covered by health insurance, including for those with MASH. As for treating MASH specifically, we have to remember that these agents are not yet approved by the FDA. I am looking forward to being able to use a GLP-1 receptor agonist like semaglutide one day with a full indication for MASH from the ESSENCE trial.2,16

I know that you see patients in your clinic every day. It really is just a matter of adding MASLD/MASH screening in the same way you already do for chronic kidney disease or eye issues. I believe that following the simple guidance from the ADA and other expert organizations will help us prevent cirrhosis in patients with MASLD/MASH.

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