AGA Clinical Practice Update on the Evaluation and Management of Metabolic Dysfunction- and Alcohol-Associated Liver...

Steatotic liver disease (SLD) is the leading cause of chronic liver disease and liver-related mortality in the United States. The 2023 multisociety consensus nomenclature was intended to develop a more evidence-based framework regarding the differing forms of SLD, including metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction- and alcohol-associated liver disease (MetALD), and alcohol-associated liver disease. The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update expert review is to provide Best Practice Advice regarding the diagnosis, staging, and treatment of MetALD.

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership. The document underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Clinical Gastroenterology and Hepatology. These BPA statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these BPA statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE STATEMENTS BEST PRACTICE ADVICE 1: Patients with SLD can be classified into MASLD, MetALD, and alcohol-associated liver disease categories by the presence of cardiometabolic risk factors and the quantity of alcohol consumed in grams per week (ideally over ≥3 months), using the thresholds of ≈140 to 350 g/wk in women and 210 to 420 g/wk in men for MetALD. BEST PRACTICE ADVICE 2: All patients with steatotic liver disease, including MetALD, should be assessed initially and at least annually thereafter for alcohol use via patient interview, completion of validated alcohol use questionnaires, and/or measurement of serum and/or urine alcohol biomarkers. BEST PRACTICE ADVICE 3: Alcohol consumption increases the extent of hepatic steatosis accumulation and fibrosis progression in a dose-dependent manner in nearly all forms of chronic liver disease, including those with MetALD. Therefore, all patients should be advised to discontinue alcohol use, recognizing that abstinence may be preceded by periods of use reduction and intermittent use. BEST PRACTICE ADVICE 4: A tiered, noninvasive strategy that combines routine blood-based biomarkers with simple fibrosis scores, such as the Fibrosis-4 Index, should be used to identify low-risk patients with MetALD and to triage those at indeterminate or high risk to second-line tests (eg, elastography or serum Enhanced Liver Fibrosis test) for detection of advanced fibrosis and cirrhosis. BEST PRACTICE ADVICE 5: Vibration-controlled transient elastography and magnetic resonance-based techniques are noninvasive tools that objectively assess the fibrosis stage and steatosis burden in patients with MetALD; however, liver stiffness values should be interpreted cautiously in the presence of active alcohol use, which can transiently increase stiffness. BEST PRACTICE ADVICE 6: Medical management of MetALD should include dietary counseling and replenishment of micronutrient deficiencies (folate, thiamine, vitamin D) as well as aerobic exercise to improve body weight and muscle mass, along with treatment of concomitant cardiometabolic risk factors. BEST PRACTICE ADVICE 7: The safety and efficacy of United States Food and Drug Administration-approved treatments for noncirrhotic MASLD (ie, resmetiron and semaglutide) has not been formally studied in MetALD. However, preliminary data suggests that glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide receptor agonists may reduce alcohol cravings and consumption and improve hepatic parameters. BEST PRACTICE ADVICE 8: Medical management of patients with MetALD and moderate or severe alcohol use disorder should include use of alcohol use disorder pharmacotherapy and behavioral approaches to reduce alcohol consumption. BEST PRACTICE ADVICE 9: Endobariatric and bariatric surgery are not advisable for patients with MetALD due to the lack of safety and efficacy data as well as concerns regarding accelerated liver disease progression with continued alcohol use after surgery.