At the recently concluded European Association for the Study of the Liver (EASL) annual meeting, Professor Frank Tacke from Charité—Universitätsmedizin Berlin presented a special report on the newly released "Clinical Practice Guidelines for the Management of Metabolic Associated Fatty Liver Disease" by EASL, the European Association for the Study of Diabetes (EASD), and the European Association for the Study of Obesity (EASO). This guideline covers the latest recommendations from the use of non-invasive diagnostic tools to treatment strategies, emphasizing the importance of managing obesity and diabetes and the need for multidisciplinary collaboration in the management of metabolic associated fatty liver disease. At the conference, Hepatology Digest invited Professor Frank Tacke to provide an authoritative interpretation of the guideline. Professor Tacke stated that this guideline is not only a significant achievement in the field of hepatology but also a major update to the global medical community's diagnostic and treatment plans for MAFLD patients. It places a stronger emphasis on practicality and operability in clinical practice, ensuring better health outcomes for MAFLD patients.Hepatology Digest: Could you provide a detailed introduction to the latest developments in weight management? What evidence-based impacts do these developments have on the treatment of MASLD and MASH?
Professor Tacke: For patients affected by MASLD and MASH, we offer different weight management approaches. On one hand, we recommend lifestyle modifications, such as low-calorie diets and improving diet quality to reduce weight. On the other hand, there is pharmacotherapy. Currently approved anti-obesity drugs include incretin-based therapies like GLP-1 receptor agonists and GLP-1/GIP dual agonists. Thirdly, weight reduction can also be achieved through surgical or endoscopic treatments, such as sleeve gastrectomy and Roux-en-Y gastric bypass surgery.
Among these three treatment strategies, we must say that from the data on lifestyle interventions, there is a strong correlation between weight loss and histological improvement in the liver. Weight loss of more than 5% significantly improves liver steatosis, and weight loss of more than 10% can also improve liver fibrosis. These positive treatment effects have not yet been fully confirmed with medications, but they have been demonstrated with bariatric surgery. Retrospective clinical trials and prospective clinical studies show that, compared to conventional management, bariatric surgery significantly improves liver fibrosis and liver-related outcomes.
Hepatology Digest: Regarding the management of MAFLD, the EASL-EASD-EASO recently jointly released the latest clinical practice guidelines for MAFLD. What are the key updates in this guideline?
Professor Tacke: This joint guideline places great emphasis on lifestyle modifications and setting realistic weight loss goals for overweight and obese patients. For patients with MASLD who have a normal weight, we recommend a weight loss of 3-5%. For overweight or obese patients with MASLD, we recommend a weight loss of 5-7% to improve steatohepatitis and sustained weight loss of over 10% to improve fibrosis. This is our target. Of course, in cases of secondary or tertiary obesity (which means a BMI of over 35 and 40, respectively, in Western populations, with adjusted BMI thresholds for non-European ethnicities), we also consider bariatric surgery as an effective weight loss measure.
We sincerely hope that this multidisciplinary, international guideline will simplify the management of patients with MASLD for physicians. Due to our common goal, this guideline provides patients with a simple, unified management approach. Additionally, I hope these guidelines will facilitate the setting of weight management goals. We have outlined different methods to achieve this goal, including lifestyle modifications, pharmacological interventions, and bariatric surgery. Ultimately, all disciplines need to work together to bring tangible benefits to patients.
Hepatology Digest: Besides weight management, what other important treatment and management measures do you believe are crucial for MASLD patients?
Professor Tacke: A critical step in managing MASLD patients is assessing the presence of progressive liver disease, fibrosis, or cirrhosis. To achieve this, the guideline recommends the use of non-invasive tests, such as blood-based FIB-4 scores and liver stiffness measurement (LSM) via transient elastography (VCTE). Numerous studies have shown that these non-invasive testing methods are crucial for accurately assessing liver-related and cardiovascular risks.
In terms of MASLD treatment, the guideline recommends a comprehensive treatment strategy, including lifestyle interventions, management of comorbidities (such as using statins to manage dyslipidemia or using metformin and GLP-1 receptor agonists to treat type 2 diabetes), and focusing on patients who may benefit from MASH-targeted therapies. Currently, the only globally approved MASH treatment drug, resmetirom, has been approved in the United States but has not yet been approved in Asia and Europe (it is expected to be approved soon). For selected cases with progressive disease or risk of disease progression, the guideline suggests considering the addition of MASH-targeted drug therapy.
