Understanding the Burden of MASH

Metabolic dysfunction-associated steatohepatitis (MASH) is rapidly becoming a leading cause of liver transplantation worldwide. In India, the prevalence of steatotic liver disease is alarmingly high, often linked to rising rates of obesity and type 2 diabetes. Consequently, effective at-risk MASH screening has become a clinical priority to identify patients at the highest risk of major adverse liver outcomes (MALO).

The Role of Semaglutide in At-risk MASH Screening

Recent data from the ESSENCE Phase 3 trial provide a significant breakthrough in pharmacologic treatment. Specifically, the trial evaluated semaglutide 2.4 mg in patients with moderate to advanced fibrosis. Furthermore, the results demonstrated that a majority of treated patients achieved resolution of steatohepatitis. This evidence underscores why accurate at-risk MASH screening is essential for selecting candidates for therapy. However, while liver biopsy remains the gold standard, its invasive nature limits its use in routine primary care and endocrine clinics.

Non-Invasive Diagnostic Pathways

To bridge the diagnostic gap, expert panels recommend a sequential testing strategy. Initially, clinicians should use simple tools like the FIB-4 index to stratify risk. Moreover, patients with suspicious findings should undergo confirmatory tests such as vibration-controlled transient elastography (VCTE) or magnetic resonance elastography (MRE). Additionally, a Controlled Attenuation Parameter (CAP) of 280 dB/m or higher, combined with elevated AST levels, serves as a strong indicator for advanced evaluation. Therefore, adopting these non-invasive tests can streamline the identification of patients who require urgent intervention.

Clinical Recommendations for Indian Doctors

In the Indian context, where metabolic syndrome is pervasive, proactive screening is vital. Practitioners should integrate these non-invasive protocols into their daily workflows for diabetic and obese patients. This approach ensures that treatment, including emerging options like semaglutide, is offered to those with the greatest clinical need. Ultimately, early detection through standardized screening remains the most effective way to halt disease progression.

Frequently Asked Questions

What is considered 'at-risk MASH' in clinical practice?

At-risk MASH is defined as the presence of steatohepatitis with a fibrosis stage of 2 or higher (F2-F3). These patients have a significantly higher risk of progressing to cirrhosis and liver-related mortality.

Which non-invasive tests are most effective?

The FIB-4 index is a widely available first-line screening tool. For confirmation, VCTE (FibroScan) and the Enhanced Liver Fibrosis (ELF) score are highly recommended due to their high predictive value for advanced fibrosis.

Disclaimer: This content is for informational and educational purposes only. It does not constitute medical advice or a professional relationship. Refer to the latest local and national guidelines for clinical practice.

References

1. Alkhouri N et al. Review Article: An Update on Non-Invasive Tests for Steatotic Liver Disease - Insights From the ESSENCE Phase 3 Trial and Longitudinal Studies. Aliment Pharmacol Ther. 2026 Apr 06. doi: 10.1111/apt.70639. PMID: 41941221.


2. Sanyal AJ, Newsome PN, Kliers I, et al. Phase 3 Trial of Semaglutide in Metabolic Dysfunction-Associated Steatohepatitis. N Engl J Med. 2025 Jun 5;392(21):2089-2099. doi: 10.1056/NEJMoa2413258.


3. Mohan V, et al. Prevalence of Metabolic Dysfunction-Associated Steatotic Liver Disease: Mapping Across Different Indian Populations (MAP Study). Indian J Endocrinol Metab. 2025.