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gi.masld.core.v1PRODUCTION
gi.masld.core.v1

MASLD / MASH (formerly NAFLD/NASH)

gastroenterologychronicadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm MASLD scope: hepatic steatosis + ≥1 cardiometabolic criterion + alcohol <20g/day (women) or <30g/day (men); distinguish MASLD from MetALD (moderate alcohol + metabolic) and ALD (Rinella Hepatology 2023)

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MASLD diagnosis confirmed per Rinella 2023 nomenclature criteria

Patient inputs (18)

FIB-4 calculation; risk stratification; guides non-invasive testing interpretation (AASLD 2023)

MASLD prevalence differs; ALT thresholds differ by sex (AASLD 2023)

Obesity is cardinal metabolic risk factor; guides lifestyle intervention intensity; lean MASLD (BMI <25) is distinct phenotype (AASLD 2023)

Hypertension as metabolic syndrome component; cardiovascular risk (AASLD 2023)

Must quantify alcohol — MASLD requires <20g/day women, <30g/day men; excess alcohol = MetALD or ALD (Rinella Hepatology 2023)

At least one cardiometabolic criterion required for MASLD diagnosis: BMI ≥25, T2DM, HTN, dyslipidemia, waist circumference (Rinella Hepatology 2023)

Steatogenic drugs (tamoxifen, amiodarone, methotrexate, corticosteroids); current diabetes/lipid/HTN meds for metabolic management (AASLD 2023)

Primary liver injury marker; persistently elevated ALT triggers advanced workup (AASLD 2023)

AST:ALT ratio; FIB-4 calculation (AASLD 2023)

FIB-4 denominator; thrombocytopenia suggests advanced fibrosis/cirrhosis (AASLD 2023)

T2DM screening/monitoring — strongest metabolic risk factor for MASH progression (AASLD 2023)

Metabolic syndrome criterion; insulin resistance assessment (AASLD 2023)

Dyslipidemia as metabolic syndrome component; cardiovascular risk (AASLD 2023)

Liver synthetic function; exclude other liver diseases (AASLD 2023)

Liver synthetic function; advanced fibrosis marker (AASLD 2023)

FIB-4 is recommended first-line non-invasive test for fibrosis risk stratification (AASLD 2023): <1.3 low risk, 1.3-2.67 indeterminate, >2.67 high risk

Vibration-controlled transient elastography (VCTE/FibroScan) — second-line for indeterminate FIB-4 (1.3-2.67) or high FIB-4 confirmation; LSM <8 kPa excludes advanced fibrosis, ≥8 kPa suggests significant fibrosis (AASLD 2023; EASL 2024)

Liver synthetic function assessment (AASLD 2023)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (3)

3 need judgement
  • informationalsevereprogression_to_cirrhosis
    MASLD progressed to cirrhosis (F4) — VCTE ≥15-20 kPa or biopsy-confirmed (AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateadvanced_fibrosis_fib4_high
    FIB-4 >2.67 — high probability of advanced fibrosis (F3-F4); hepatology referral required (AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateresmetirom_hepatotoxicity
    ALT >5× ULN on resmetirom therapy — hold drug and evaluate (FDA label 2024; Harrison NEJM 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Lifestyle intervention — cornerstone of MASLD treatment (AASLD 2023)
axis: masld_lifestyle_axis
Selected axis "Lifestyle intervention — cornerstone of MASLD treatment (AASLD 2023)" by default fallback (first axis)
  • lifestyle_weight_loss
    first line
    lifestyle
    ≥5% body weight loss for steatosis resolution; ≥7-10% for MASH/inflammation resolution; ≥10% for fibrosis regression
    AASLD 2023 — weight loss is the most effective intervention; Mediterranean diet preferred; caloric deficit 500-1000 kcal/day; 150-300 min/week moderate-intensity exercise
  • bariatric_surgery
    second line
    surgical
    BMI ≥35 (or ≥30 with metabolic comorbidities) with MASH
    triggers: BMI_>=35_with_MASH, failed_lifestyle_with_BMI_>=30
    AASLD 2023 — bariatric surgery achieves sustained weight loss and MASH resolution in most patients; observational evidence of fibrosis improvement

outpatient playbook — drug actions (7)

  1. 1. lifestyle — caloric restriction + exercise
    500-1000 kcal/day deficit; Mediterranean diet; 150-300 min/week moderate exercise • N/A • daily
    trigger: All MASLD patients
    AASLD 2023 — first-line; ≥5% loss resolves steatosis, ≥7-10% resolves MASH
  2. 2. pioglitazone
    30 mg PO daily (may increase to 45 mg) • PO • daily
    trigger: MASH confirmed (biopsy or high clinical suspicion) with or without T2DM
    PIVENS (Sanyal NEJM 2010); Cusi Annals IM 2016
  3. 3. vitamin E
    800 IU PO daily • PO • daily
    trigger: Non-diabetic, non-cirrhotic MASH
    PIVENS (Sanyal NEJM 2010)
  4. 4. semaglutide
    0.25 mg SC weekly, escalate to 2.4 mg weekly • SC • weekly
    trigger: MASH + T2DM or obesity
    Newsome Lancet Gastro 2021
  5. 5. resmetirom
    80 mg PO daily (<100 kg) or 100 mg PO daily (≥100 kg) • PO • daily
    trigger: MASH with F2-F3 fibrosis
    MAESTRO-NASH (Harrison NEJM 2024) — first FDA-approved MASH drug
  6. 6. statin (e.g., atorvastatin)
    10-80 mg PO daily per ASCVD risk • PO • daily
    trigger: Dyslipidemia or elevated ASCVD risk
    AASLD 2023 — safe in MASLD + compensated cirrhosis; CV death is #1 cause
  7. 7. metformin (for T2DM, not for MASH)
    500-1000 mg PO BID • PO • BID
    trigger: T2DM management
    AASLD 2023 — does not improve MASH histology but appropriate for glycemic control

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Incidentally elevated ALT or hepatic steatosis on imaging; Hepatic steatosis on US/CT/MRI; Elevated FIB-4 score (≥1.3) on routine screening in at-risk population.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**MASLD / MASH (formerly NAFLD/NASH)** (gi.masld.core.v1).
Phenotype framing: MASLD vs MetALD (alcohol 20-50g/day women, 30-60g/day men + metabolic) vs ALD (excess alcohol) vs drug-induced steatosis (amiodarone, tamoxifen, MTX, steroids) vs other chronic liver disease; MASH vs simple steatosis (requires biopsy or biomarker) (Rinella Hepatology 2023; AASLD 2023)
Scope: Confirm MASLD scope: hepatic steatosis + ≥1 cardiometabolic criterion + alcohol <20g/day (women) or <30g/day (men); distinguish MASLD from MetALD (moderate alcohol + metabolic) and ALD (Rinella Hepatology 2023)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Lifestyle intervention — cornerstone of MASLD treatment (AASLD 2023)**.
1. lifestyle_weight_loss ≥5% body weight loss for steatosis resolution; ≥7-10% for MASH/inflammation resolution; ≥10% for fibrosis regression (lifestyle, first line) — AASLD 2023 — weight loss is the most effective intervention; Mediterranean diet preferred; caloric deficit 500-1000 kcal/day; 150-300 min/week moderate-intensity exercise
2. bariatric_surgery BMI ≥35 (or ≥30 with metabolic comorbidities) with MASH (surgical, second line) — AASLD 2023 — bariatric surgery achieves sustained weight loss and MASH resolution in most patients; observational evidence of fibrosis improvement

Setting playbook (outpatient) — Risk-stratify fibrosis (FIB-4 → VCTE pathway); lifestyle intervention (≥7-10% weight loss); pharmacotherapy for MASH (pioglitazone/vitamin E/GLP-1RA/resmetirom); aggressive cardiovascular risk reduction; metabolic comorbidity management
3. lifestyle — caloric restriction + exercise 500-1000 kcal/day deficit; Mediterranean diet; 150-300 min/week moderate exercise N/A daily — All MASLD patients (AASLD 2023 — first-line; ≥5% loss resolves steatosis, ≥7-10% resolves MASH)
4. pioglitazone 30 mg PO daily (may increase to 45 mg) PO daily — MASH confirmed (biopsy or high clinical suspicion) with or without T2DM (PIVENS (Sanyal NEJM 2010); Cusi Annals IM 2016)
5. vitamin E 800 IU PO daily PO daily — Non-diabetic, non-cirrhotic MASH (PIVENS (Sanyal NEJM 2010))
6. semaglutide 0.25 mg SC weekly, escalate to 2.4 mg weekly SC weekly — MASH + T2DM or obesity (Newsome Lancet Gastro 2021)
7. resmetirom 80 mg PO daily (<100 kg) or 100 mg PO daily (≥100 kg) PO daily — MASH with F2-F3 fibrosis (MAESTRO-NASH (Harrison NEJM 2024) — first FDA-approved MASH drug)
8. statin (e.g., atorvastatin) 10-80 mg PO daily per ASCVD risk PO daily — Dyslipidemia or elevated ASCVD risk (AASLD 2023 — safe in MASLD + compensated cirrhosis; CV death is #1 cause)
9. metformin (for T2DM, not for MASH) 500-1000 mg PO BID PO BID — T2DM management (AASLD 2023 — does not improve MASH histology but appropriate for glycemic control)

Non-pharmacologic actions:
- Mediterranean diet counselling (AASLD 2023)
- Exercise prescription: 150-300 min/week moderate-intensity aerobic + resistance training (AASLD 2023)
- Weight loss target: ≥7-10% for MASH; ≥5% for steatosis alone (AASLD 2023)
- Alcohol cessation counselling — any excess alcohol accelerates fibrosis (AASLD 2023)
- Bariatric surgery referral if BMI ≥35 (or ≥30 with metabolic comorbidities) and MASH (AASLD 2023)
- Coffee consumption encouraged — ≥3 cups/day associated with reduced fibrosis progression (AASLD 2023)
- Cardiovascular risk factor optimization — leading cause of mortality (AASLD 2023)

AVOID / contraindication checks:
- Crash_diets avoid — rapid weight loss can worsen steatohepatitis and cause gallstones (AASLD 2023)
- Weight_loss_target — 0.5 1 kg/week gradual loss preferred (AASLD 2023)

Monitoring

Regimen monitoring:
- Weight at each visit (AASLD 2023)
- Waist circumference q6-12mo (AASLD 2023)
- ALT q6-12mo to assess biochemical response (AASLD 2023)
- FIB-4 q1-2 years (AASLD 2023)

Setting (outpatient) monitoring:
- ALT q6-12mo (AASLD 2023)
- FIB-4 q1-2 years (AASLD 2023)
- VCTE q1-2 years if prior indeterminate/high FIB-4 (AASLD 2023)
- Weight, BMI at each visit (AASLD 2023)
- HbA1c q3-6mo if T2DM (ADA 2026)
- Lipid panel annually (AASLD 2023)
- Resmetirom: ALT/AST q3mo × first year (FDA label 2024)
- HCC surveillance (US + AFP q6mo) if cirrhosis (AASLD 2023)

Follow-up plan: Lifestyle reinforcement; weight loss maintenance; medication adherence; cardiovascular risk reduction (leading cause of death in MASLD); HCC surveillance if cirrhotic; consideration of bariatric surgery if BMI ≥35 with MASH (AASLD 2023)
- Close-out criterion: follow-up scheduled

Monitoring phase: FIB-4 reassessment q1-2 years for low-risk; VCTE q1-2 years for indeterminate/high risk; ALT q6-12mo; HbA1c q3-6mo if T2DM; lipids annually; HCC surveillance (US + AFP q6mo) if cirrhosis (AASLD 2023; EASL 2024)

Disposition

Current setting: outpatient — Risk-stratify fibrosis (FIB-4 → VCTE pathway); lifestyle intervention (≥7-10% weight loss); pharmacotherapy for MASH (pioglitazone/vitamin E/GLP-1RA/resmetirom); aggressive cardiovascular risk reduction; metabolic comorbidity management

Disposition criteria:
- Low-risk MASLD (FIB-4 <1.3): primary care management with lifestyle; reassess FIB-4 q2-3 years (AASLD 2023)
- Indeterminate risk (FIB-4 1.3-2.67, VCTE ≥8 kPa): hepatology co-management (AASLD 2023)
- High-risk / cirrhosis: hepatology-led with HCC surveillance and transplant consideration (AASLD 2023)

Escalation triggers (move to higher acuity):
- FIB-4 rising to ≥2.67 → hepatology referral (AASLD 2023)
- VCTE LSM ≥8 kPa → hepatology referral (AASLD 2023)
- Progression to cirrhosis → cirrhosis engine (gi.cirrhosis.core.v1)
- Decompensation event (ascites, variceal bleed, HE) → inpatient cirrhosis management (AASLD 2023)
- Drug-induced ALT >5× ULN on resmetirom → hold and reassess (FDA label 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] MASLD progressed to cirrhosis (F4) — VCTE ≥15-20 kPa or biopsy-confirmed (AASLD 2023)
- [MODERATE] FIB-4 >2.67 — high probability of advanced fibrosis (F3-F4); hepatology referral required (AASLD 2023)
- [MODERATE] ALT >5× ULN on resmetirom therapy — hold drug and evaluate (FDA label 2024; Harrison NEJM 2024)

Citations

- AASLD 2023 Practice Guidance on Clinical Assessment and Management of NAFLD/MASLD + EASL 2024 Clinical Practice Guidelines on MASLD + Rinella Hepatology 2023 (nomenclature) + PIVENS (Sanyal NEJM 2010) + MAESTRO-NASH (Harrison NEJM 2024) [PMID:36727674](https://pubmed.ncbi.nlm.nih.gov/36727674/)
- Cited evidence (PMID 37364790) [PMID:37364790](https://pubmed.ncbi.nlm.nih.gov/37364790/)
- Cited evidence (PMID 20427778) [PMID:20427778](https://pubmed.ncbi.nlm.nih.gov/20427778/)
- Cited evidence (PMID 38324483) [PMID:38324483](https://pubmed.ncbi.nlm.nih.gov/38324483/)
- Cited evidence (PMID 33185364) [PMID:33185364](https://pubmed.ncbi.nlm.nih.gov/33185364/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AASLD 2023 Practice Guidance on Clinical Assessment and Management of NAFLD/MASLD + EASL 2024 Clinical Practice Guidelines on MASLD + Rinella Hepatology 2023 (nomenclature) + PIVENS (Sanyal NEJM 2010) + MAESTRO-NASH (Harrison NEJM 2024) — PMID:36727674
  • Cited evidence (PMID 37364790) — PMID:37364790
  • Cited evidence (PMID 20427778) — PMID:20427778
  • Cited evidence (PMID 38324483) — PMID:38324483
  • Cited evidence (PMID 33185364) — PMID:33185364