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MASH Matters Multidisciplinary Care
MASH Matters: A Multidisciplinary Approach to Diagnosis, Staging, and Treatment

Released: February 26, 2025

Expiration: February 25, 2026

Jay H. Shubrook
Jay H. Shubrook, DO, FACOFP, FAAFP
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Key Takeaways
  • Patients with type 2 diabetes, 2 or more metabolic risk factors, or elevated liver enzymes or hepatic steatosis found via imaging should be screened for MASH.
  • Noninvasive screening with FIB-4 and vibration-controlled elastography allows for effective risk stratification, reduced referrals to hepatology, and timely care for those at high risk.
  • A multidisciplinary approach to MASH care is essential for improving patient outcomes, such as preventing disease progression.

Metabolic dysfunction–associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis, is a silent but serious condition affecting millions worldwide. Despite its prevalence, many healthcare professionals (HCPs), particularly in primary care, remain unaware of its significance. With the rise of metabolic syndrome, obesity, and type 2 diabetes (T2D), MASH is quickly becoming one of the most common causes of cirrhosis and hepatocellular carcinoma (HCC).

As HCPs, we must recognize that MASH is not just a liver disease; it is a systemic condition with significant implications for cardiovascular disease, metabolic health, and malignancy risk. Nearly one third of the global adult population has metabolic dysfunction–associated steatotic liver disease (MASLD)—the overarching term that includes MASH. In individuals with T2D, the prevalence of MASLD exceeds 60%, highlighting the intertwined nature of metabolic and liver health.

Disease Burden and Systemic Impact
The dangers of MASH extend beyond the liver. In addition to increasing the risk of cirrhosis and HCC, patients with MASH have a significantly higher risk of cardiovascular disease and extrahepatic cancers. The condition is silent, with no obvious symptoms, yet it has serious long-term consequences. Since we now have noninvasive screening tools, there is no reason for MASH to go undiagnosed. The challenge is that MASH is often overlooked, leading to missed opportunities for intervention. However, if we embrace a multidisciplinary approach and utilize available screening methods, we can identify at-risk patients earlier and provide more effective care.

Noninvasive Screening Strategies for MASH
Historically, diagnosing MASH required liver biopsy, which is an invasive and often impractical method for most primary care settings. Fortunately, noninvasive screening methods have transformed our ability to identify at-risk patients efficiently. Few people will need a liver biopsy if these screening regimens are enacted properly.

Current guidelines recommend screening all patients T2D, 2 or more metabolic risk factors (eg, obesity, hypertension, or dyslipidemia), or incidentally found to have elevated liver enzymes or hepatic steatosis via imaging. The first step in screening is calculating the fibrosis-4 (FIB-4) index—an equation that uses patients’ age, aspartate aminotransferase, alanine aminotransferase, and platelet count to estimate liver fibrosis risk. Patients with a FIB-4 score below 1.3 if aged 65 or younger or below 2.0 if aged older than 65, they are considered low risk. Their management can remain with primary care. This care should focus on treating metabolic conditions with a priority on weight loss, avoiding alcohol, and cardiovascular risk reduction. However, if the FIB-4 score is above either of these thresholds, additional assessment and imaging are needed to confirm the severity of liver involvement.

For patients with an elevated FIB-4 score, vibration-controlled elastography (VCTE) provides further assessment of both liver stiffness, which indicates fibrosis severity, and fat content, which determines the degree of steatosis. When used in combination with FIB-4, VCTE can significantly enhance HCPs’ diagnostic accuracy; therefore, allowing us to identify which patients require referral to hepatology vs those who can continue to be managed by their primary care provider (PCP). This 2-step screening approach has allowed me to substantially reduce unnecessary referrals to hepatology, ensuring that only those patients at genuine risk for advanced fibrosis or cirrhosis receive specialized care.

Finally, patients with MASH and fibrosis require long-term monitoring. Those at low risk based on initial screening should be reassessed for MASH every 2 to 3 years, while those at high risk require annual monitoring to track disease progression and/or treatment response.

The Role of Multidisciplinary Care
Managing MASH effectively requires a multidisciplinary team-based approach that includes PCPs, endocrinologists, hepatologists, and dietitians. Although hepatologists and gastroenterologists play a critical role in diagnosing and treating advanced disease, PCPs and endocrinologists are on the frontline with initial screening, metabolic management, and lifestyle interventions. HCPs in these settings should ensure at-risk patients are screened appropriately, focus on weight management and cardiovascular risk reduction, and implement effective dietary and exercise interventions. Collaborating with dietitians and lifestyle coaches can enhance patient adherence to these recommendations.

Hepatologists also play an important role in confirming a MASH diagnosis and initiating specialized therapies for those with significant fibrosis. However, care does not stop once a patient is referred. PCPs and endocrinologists must continue to work with hepatologists to ensure patients receive comprehensive management. Ongoing communication between specialties prevents unnecessary repeat testing and ensures treatments are aligned. For example, if hepatologists initiate a glucagon-like peptide-1 (GLP-1) receptor agonist or pioglitazone, PCPs should be informed so they can monitor for effectiveness and potential adverse events. This care coordination ultimately improves patient outcomes and ensures treatment plans remain comprehensive and individualized.

Current and Emerging Therapies for MASH
Although lifestyle modifications remain the cornerstone of MASH management, and weight loss should be the primary therapeutic target, several pharmacologic options show promise. Pioglitazone reduces hepatic inflammation by shifting fat storage from the liver to subcutaneous tissue. GLP-1 receptor agonists like semaglutide and dual GIP/GLP-1 agonists like tirzepatide have demonstrated potential in reducing fibrosis and improving metabolic health. In addition, resmetirom was the first FDA-approved treatment, in conjunction with diet and exercise, for MASH with moderate to advanced fibrosis (F2 to F3), and it is now available. Although it is primarily used by hepatologists, its role may expand in the future.

Your Thoughts
As we continue to advance our understanding of MASH, we must ask ourselves: How are we currently screening for MASH in our practice? Are we using FIB-4 and VCTE as standard screening tools? What challenges do we face in coordinating care with specialists? By sharing insights and experiences, we can refine our approach and ensure that patients receive the best possible care. You can get involved by answering the polling question and posting a comment below.

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How often do you use FIB-4 and and/or VCTE as standard screening tools for MASH for patients who qualify?

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