Management of Hepatic Steatosis
Begin with risk stratification using FIB-4 score to determine fibrosis risk, then implement intensive lifestyle modification targeting 7-10% weight loss through Mediterranean diet and 150-300 minutes weekly of moderate-intensity exercise, while optimizing cardiometabolic comorbidities with GLP-1 receptor agonists or SGLT2 inhibitors for diabetes, and statins for dyslipidemia. 1
Risk Stratification First
Calculate FIB-4 score immediately to stratify patients into risk categories 1, 2:
- Low risk: FIB-4 <1.3 (manage in primary care with lifestyle modification)
- Intermediate risk: FIB-4 1.3-2.67 (refer to hepatology for transient elastography)
- High risk: FIB-4 >2.67 (immediate hepatology referral)
For intermediate/high-risk patients, obtain liver stiffness measurement by transient elastography, with LSM >12.0 kPa indicating advanced fibrosis requiring hepatology co-management 1, 2
Common pitfall: Do not skip risk stratification—approximately 10% of patients with hepatic steatosis have clinically significant fibrosis requiring specialized management 2
Lifestyle Modification (Foundation for All Patients)
Weight Loss Targets
Target 7-10% weight loss to improve steatohepatitis and potentially reverse fibrosis 1, 2. Even modest weight loss of 3-5% improves steatosis, but the higher target is needed for inflammation and fibrosis regression 2. Implement a 500-1,000 kcal/day deficit to achieve gradual weight loss 3.
Dietary Prescription
Prescribe a Mediterranean diet pattern as the primary dietary intervention 1, 2:
- Daily vegetables, fresh fruits, unsweetened fiber-rich cereals, nuts, fish or white meat, and olive oil
- Minimize simple sugars, red meat, processed meats, and ultra-processed foods
- Avoid sugar-sweetened beverages completely
- Limit total carbohydrates to 40% of calories (vs. 50-60% in typical low-fat diets), with increased monounsaturated and omega-3 fatty acids to 40% of calories 4
Mediterranean diet reduces hepatic steatosis even without weight loss and improves insulin sensitivity 1, 4
Alcohol Restriction
Mandate complete alcohol abstinence or at minimum restrict to zero, as even 9-20g daily alcohol intake doubles the risk for adverse liver-related outcomes in patients with hepatic steatosis 1, 5
Exercise Prescription
Prescribe 150-300 minutes of moderate-intensity exercise OR 75-150 minutes of vigorous-intensity exercise per week 1, 2. Physical activity decreases aminotransferases and steatosis even without significant weight loss 1. Aerobic exercise at 65-75% maximum heart rate is particularly effective 1.
Pharmacologic Management of Cardiometabolic Comorbidities
Diabetes Management
Prioritize GLP-1 receptor agonists (semaglutide, tirzepatide, liraglutide) as first-line agents for patients with type 2 diabetes, as they improve both glycemic control and liver histology 1, 5, 2, 3
SGLT2 inhibitors (empagliflozin, dapagliflozin) are preferred alternatives with beneficial effects on liver outcomes 1, 5, 6
Metformin can be used but only in compensated disease with preserved renal function (GFR >30 ml/min); it is contraindicated in cirrhosis due to lactic acidosis risk 5
Dyslipidemia Management
Statins are safe and strongly recommended for all patients with dyslipidemia and hepatic steatosis 1, 5, 2, 3. Statins reduce hepatocellular carcinoma risk by 37% and have beneficial pleiotropic properties 3. There is no increased risk of drug-induced liver injury from statins in this population 3.
Common pitfall: Do not withhold statins based on hepatic steatosis diagnosis alone—they are both safe and beneficial 5, 3
Hypertension Management
Manage hypertension according to standard guidelines, as optimal blood pressure control reduces cardiovascular risk, which is the leading cause of death in MASLD patients 1, 2
Advanced Disease Considerations
Bariatric Surgery
Consider bariatric surgery in patients with obesity (BMI ≥35 with comorbidities or ≥40) and hepatic steatosis, particularly those with significant fibrosis 1, 2. Bariatric surgery requires multidisciplinary evaluation and is effective for both weight loss and liver disease improvement 1.
MASH-Targeted Pharmacotherapy
For patients with non-cirrhotic MASH and significant fibrosis (stage ≥2), consider resmetirom if locally approved, as it demonstrates histological effectiveness on steatohepatitis and fibrosis 1
No MASH-targeted pharmacotherapy is currently recommended for cirrhotic stage disease 1, 5
Cirrhosis Management
For patients progressing to cirrhosis 5:
- Immediate hepatology referral for all cirrhotic patients
- High-protein diet (1.2-1.5 g/kg/day) with total calories ≥35 kcal/kg/day to prevent sarcopenia
- Late-evening snack to reduce overnight fasting
- Surveillance for portal hypertension and hepatocellular carcinoma
- Liver transplantation evaluation if decompensation occurs (ascites, variceal bleeding, hepatic encephalopathy)
Common pitfall: Do not use aggressive caloric restriction in cirrhotic patients, as this worsens sarcopenia 5
Monitoring Strategy
For low-risk patients, perform annual follow-up with repeated FIB-4 calculation to monitor for fibrosis progression 2, 3. Obtain baseline and follow-up liver enzymes, complete blood count, and metabolic panel 2.
For intermediate/high-risk patients, coordinate care between primary care, hepatology, and endocrinology as needed 3